Our Solutions


Health plans that serve Medicare members must provide high-quality care while complying with government regulations.

UMMS' Success with HealthRules
Claims Processed & Paid Within a Week
Auto-Adjudication Rate
4 Weeks
Into Implementation, First Claim Processed

HealthEdge’s HealthRules suite enables health plans serving Medicare and Medicare Advantage markets to tackle critical imperatives including:

  • Enroll and reconcile members efficiently and accurately
  • Identify and provide care to high-risk populations and members with high utilization
  • Receive the highest STAR ratings for quality of care and clinical outcomes, raising reimbursements
  • Achieve and maintain regulatory compliance as new rules emerge
  • Track and report on critical quality and compliance measures
  • Deliver transparency of information for superior customer experience
  • Lower administrative costs significantly by automating everything
  • Leverage key data sources with seamless integration
  • Coordinate individuals’ healthcare and support services effectively

Medicare and Medicare Advantage businesses striving to stay ahead in today’s competitive and dynamic marketplace recognize the importance of having the latest technology platform. HealthEdge Medicare customers achieve greater levels of operational efficiency, lower costs, and deliver enhanced levels of transparency and customer service while providing  compliant and high-quality care with the HealthRules product suite.

Case Study
Bringing Innovation to a Local Population

University of Maryland Medical Systems (formerly Riverside Health Plan), a start-up health plan born from the Affordable Care Act (ACA), UMMS serves primarily Medicare and Medicaid members and leverages HealthRules to benefit their business.

Market Brief
Medicare: State of the State CMS RULINGS TO EXPECT IN 2019 AND BEYOND

As the largest payer in the US, CMS is focused on key priorities to allow access to services, improve outcomes and control costs. Some areas of emphasis in 2019 include adding reimbursements for remote patient monitoring and telehealth, incorporating considerations for Social Determinants of Health, and helping to drive the growth and popularity of Medicare Advantage plans.