healthedge-caps

JSON twin: https://www.healthaidb.com/software/healthedge-caps.json

Company Name

HealthEdge

Product URL

https://healthedge.com/solutions/core-administrative-processing-systems/

Company URL

https://healthedge.com

Categories

Summary

HealthEdge CAPS (HealthRules Payer) is a next-generation core administrative processing system (CAPS) that automates health plan administration including configurable claims adjudication, integrations, and analytics for payers.

Description

HealthEdge's HealthRules Payer is a cloud-deployable, configurable CAPS suite providing claims adjudication, benefits configuration, payment integrity and integrated modules for BI, provider data management, promotion/configuration deployment, machine-readable file publishing, and ecosystem integrations to support commercial, Medicare, Medicaid and dual-eligible health plans.

Api Available

yes

Certifications

Company Founding

2005

Company Offices

Compliance

Customers

Data Residency

Public and private cloud hosting options; specific region/residency selectable per deployment (contact vendor)

Data Standards

Deployment Model

Features

Id

P0704

Integration Partners

Integrations

Languages Supported

Last Updated

2025-09-07

License

commercial proprietary

Links

Market Segment

Optional Modules

Os Platforms

Pricing Details

Contact vendor for pricing, enterprise quotes and implementation estimates; demo/request-a-demo and vendor sales required.

Pricing Model

enterprise_quote

Privacy Features

Ratings

Regions Available

Release Year

Security Features

Specialties

Support Channels

System Requirements

Target Users

Training Options

Type

product

User Reviews

Version

1.0

Canonical JSON

{
  "company_name": "HealthEdge",
  "company_url": "https://healthedge.com",
  "company_offices": [
    "United States",
    "India"
  ],
  "company_founding": "2005",
  "product_url": "https://healthedge.com/solutions/core-administrative-processing-systems/",
  "categories": [
    "administrative",
    "payer",
    "claims management",
    "payment integrity",
    "interoperability",
    "analytics"
  ],
  "market_segment": [
    "enterprise",
    "health plans"
  ],
  "links": [
    "https://healthedge.com/solutions/core-administrative-processing-systems/",
    "https://healthedge.com/solutions/core-administrative-processing-systems/healthrules-payer/",
    "https://healthedge.com/about-us/",
    "https://healthedge.com/about-us/careers/us-offices/",
    "https://healthedge.com/resources/press-releases/healthedge-caps-solution-chosen-by-legato-health-technologies-as-it-enters-bpaas-space-serving-health-plans",
    "https://healthedge.com/resources/healthrules-payer/hrp-healthedge-s-healthrules-payor-ranked-1-in-caps-and-named-best-in-klas",
    "https://healthedge.com/resources/case-studies/healthrules-payer-case-study-with-presbyterian",
    "https://healthedge.com/resources/data-sheets/healthedge-source-product-overview",
    "https://healthedge.com/home/support/",
    "https://healthedge.com/contact-us/"
  ],
  "summary": "HealthEdge CAPS (HealthRules Payer) is a next-generation core administrative processing system (CAPS) that automates health plan administration including configurable claims adjudication, integrations, and analytics for payers.",
  "description": "HealthEdge's HealthRules Payer is a cloud-deployable, configurable CAPS suite providing claims adjudication, benefits configuration, payment integrity and integrated modules for BI, provider data management, promotion/configuration deployment, machine-readable file publishing, and ecosystem integrations to support commercial, Medicare, Medicaid and dual-eligible health plans.",
  "target_users": [
    "health plan administrators",
    "claims processors",
    "payment integrity analysts",
    "product/configuration analysts",
    "IT/integration engineers",
    "data analysts/business intelligence teams",
    "provider data managers",
    "customer service/operations staff"
  ],
  "specialties": [
    "health insurance administration",
    "claims adjudication",
    "payment integrity",
    "provider data management",
    "care management integration",
    "member engagement",
    "regulatory reporting",
    "machine-readable files"
  ],
  "regions_available": [
    "United States"
  ],
  "languages_supported": [
    "English"
  ],
  "pricing_model": "enterprise_quote",
  "pricing_details": "Contact vendor for pricing, enterprise quotes and implementation estimates; demo/request-a-demo and vendor sales required.",
  "license": "commercial proprietary",
  "deployment_model": [
    "SaaS",
    "public_cloud",
    "private_cloud",
    "hybrid"
  ],
  "os_platforms": [
    "Web"
  ],
  "features": [
    "Core claims administration and processing (HealthRules Payer)",
    "Configurable rules engine and natural-language/object-oriented configuration",
    "Business intelligence and real-time analytics (HealthRules Answers)",
    "Integration layer for partner systems and exchanges (HealthRules Connector)",
    "Promotion and configuration lifecycle management (HealthRules Promote)",
    "Home & host plan support (multi-tenant/home-host capabilities)",
    "Machine Readable Files publishing (MRF Suite)",
    "Provider data ingestion, enrichment and single source of truth",
    "Event-based, real-time API data distribution",
    "Support for prospective payment integrity integration (HealthEdge Source)",
    "Automation and workflow for claims editing and pricing",
    "Generative AI–powered provider data enrichment",
    "Audit and reporting capabilities",
    "Scalable cloud-deployed architecture"
  ],
  "optional_modules": [
    "HealthRules Answers (BI/analytics)",
    "HealthRules Connector (integration layer)",
    "HealthRules Promote (configuration & promotion)",
    "HealthRules Machine Readable Files Suite",
    "Provider Data Management",
    "Home & Host capabilities",
    "HealthEdge Source (payment integrity) "
  ],
  "integrations": [
    "HealthEdge Source (payment integrity)",
    "Wellframe (member engagement)",
    "GuidingCare (care management workflow)",
    "Provider Data Management (native module)",
    "Partner networks and exchanges via HealthRules Connector"
  ],
  "data_standards": [
    "FHIR",
    "HL7 v2",
    "X12 (837/835)"
  ],
  "api_available": "yes",
  "system_requirements": "",
  "compliance": [
    "HIPAA",
    "HITECH",
    "SOC 2"
  ],
  "certifications": [],
  "security_features": [
    "Encryption (data in transit & at rest)",
    "Role-based access control (RBAC)",
    "SSO/SAML support",
    "Audit logging",
    "Multi-factor authentication (2FA)"
  ],
  "privacy_features": [
    "Business Associate Agreement (BAA) available",
    "Consent management support",
    "Data anonymization/ masking capabilities"
  ],
  "data_residency": "Public and private cloud hosting options; specific region/residency selectable per deployment (contact vendor)",
  "customers": [
    "McLaren Health Plan",
    "Medica",
    "Community Health Options",
    "Presbyterian",
    "Legato Health Technologies"
  ],
  "user_reviews": [],
  "ratings": [
    "Best in KLAS — Claims & Administration Platforms (HealthRules Payer) — KLAS Research (named Best in KLAS 2022–2024)",
    "Ranked #1 in CAPS in KLAS performance report — KLAS Research / Business Wire (2022)"
  ],
  "support_channels": [
    "support portal/ticketing",
    "professional services",
    "customer success",
    "email"
  ],
  "training_options": [
    "documentation",
    "webinars",
    "live_online (implementation/onboarding)",
    "onsite (professional services)"
  ],
  "release_year": "",
  "integration_partners": [],
  "id": "P0704",
  "slug": "healthedge-caps",
  "type": "product",
  "version": "1.0",
  "last_updated": "2025-09-07",
  "links_json": {
    "self": "https://www.healthaidb.com/software/healthedge-caps.json"
  }
}