HealthRules Payer

JSON twin: https://www.healthaidb.com/software/healthrules-payer.json

Company Name

HealthEdge

Product URL

https://www.healthedge.com/healthrules-payer

Company URL

https://www.healthedge.com

Categories

• administrative Operations
• payer Solutions
• revenue Cycle
• payment Solutions
• data Integration
• health Data Analytics
• Administrative
• Payer
• Claims Management
• Payment Integrity
• Interoperability
• Analytics

Summary

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

Description

HealthRules Payer is a cloud-deployable, configurable Core Administrative Processing System (CAPS) suite providing claims adjudication, benefits configuration, payment integrity, and integrated modules for business intelligence, 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

• HITRUST CSF Certification

Company Founding

2004

Company Offices

• United States

Compliance

• HIPAA
• HITECH
• SOC 2

Customers

• HealthEdge Software

Data Residency

Public and private cloud hosting options; specific region/residency selectable per deployment

Data Standards

• FHIR
• HL7 v2
• X12 (837/835)

Deployment Model

• SaaS
• public_cloud
• private_cloud
• hybrid

Features

• Core claims administration and processing
• Configurable rules engine
• Business intelligence and real-time analytics
• Integration layer for partner systems and exchanges
• Promotion and configuration lifecycle management
• Provider data ingestion and enrichment
• Event-based, real-time API data distribution
• Support for prospective payment integrity integration
• Automation and workflow for claims editing and pricing
• Generative AI–powered provider data enrichment
• Audit and reporting capabilities
• Scalable cloud-deployed architecture

Id

SW1457

Integration Partners

• TriZetto Facets
• TriZetto QNXT
• Veradigm Revenue Cycle Services
• Zelis
• NaviNet Open
• Simple Fractal
• Veradigm Payerpath
• intelliPath ePA

Integrations

• HealthEdge Source
• Wellframe
• GuidingCare
• Provider Data Management
• Partner networks and exchanges via HealthRules Connector

Languages Supported

• English

Last Updated

2025-10-11

License

commercial

Market Segment

• enterprise
• smb

Optional Modules

• HealthRules Answers
• HealthRules Connector
• HealthRules Promote
• HealthRules Machine Readable Files Suite

Os Platforms

• Web

Pricing Details

contact vendor

Pricing Model

subscription

Privacy Features

• Business Associate Agreement (BAA) available
• Consent management support
• Data anonymization/masking capabilities

Product Code

SW1457

Product Name

HealthRules Payer

Ratings

• 4.5/5 (G2)

Regions Available

• United States

Related Urls

• https://elion.health/products/healthedge

Release Year

2005

Security Features

• Encryption (data in transit & at rest)
• Role-based access control (RBAC)
• SSO/SAML support
• Audit logging
• Multi-factor authentication (2FA)

Specialties

• Claims Adjudication
• Benefits Configuration
• Payment Integrity
• Provider Data Management
• Business Intelligence
• Promotion/configuration Deployment
• Machine-readable File Publishing
• Ecosystem Integrations

Support Channels

• email
• phone
• chat
• ticketing
• community
• 24x7

System Requirements

Target Users

• health plans
• payers
• administrators

Training Options

• documentation
• webinars
• live_online
• onsite
• certification

Type

product

User Reviews

• Such a fantastic tool to use and more things to know.
• The one-step easy procedure. That is the best. Also, I am a prior user of Apria but HealthRules Payor is way much better that I now use it.
• Healthrules payor, you're a life save :)) Thank you so much.
• The integration you guys have is super easy. Healthrules payor has great operational efficiency. It saves time and the co-pay is less.
• The interface is much easier than anything else out there. Also, the compatibility with all the functions is great, the process has become much more easy to do the task.
• It's a comprehensive set of available services.
• Latest technology to help turn today's challenges into tomorrow's opportunities.

Version

1.0

Alternatives

See related products

Canonical JSON

{
  "product_name": "HealthRules Payer",
  "company_name": "HealthEdge",
  "product_url": "https://www.healthedge.com/healthrules-payer",
  "company_url": "https://www.healthedge.com",
  "related_urls": [
    "https://elion.health/products/healthedge"
  ],
  "product_code": "SW1457",
  "summary": "HealthRules Payer is a next-generation core administrative processing system that automates health plan administration, including configurable claims adjudication, integrations, and analytics for payers.",
  "description": "HealthRules Payer is a cloud-deployable, configurable Core Administrative Processing System (CAPS) suite providing claims adjudication, benefits configuration, payment integrity, and integrated modules for business intelligence, provider data management, promotion/configuration deployment, machine-readable file publishing, and ecosystem integrations to support commercial, Medicare, Medicaid, and dual-eligible health plans.",
  "categories": [
    "administrative Operations",
    "payer Solutions",
    "revenue Cycle",
    "payment Solutions",
    "data Integration",
    "health Data Analytics",
    "Administrative",
    "Payer",
    "Claims Management",
    "Payment Integrity",
    "Interoperability",
    "Analytics"
  ],
  "market_segment": [
    "enterprise",
    "smb"
  ],
  "target_users": [
    "health plans",
    "payers",
    "administrators"
  ],
  "specialties": [
    "Claims Adjudication",
    "Benefits Configuration",
    "Payment Integrity",
    "Provider Data Management",
    "Business Intelligence",
    "Promotion/configuration Deployment",
    "Machine-readable File Publishing",
    "Ecosystem Integrations"
  ],
  "regions_available": [
    "United States"
  ],
  "languages_supported": [
    "English"
  ],
  "pricing_model": "subscription",
  "pricing_details": "contact vendor",
  "license": "commercial",
  "company_offices": [
    "United States"
  ],
  "company_founding": "2004",
  "deployment_model": [
    "SaaS",
    "public_cloud",
    "private_cloud",
    "hybrid"
  ],
  "os_platforms": [
    "Web"
  ],
  "features": [
    "Core claims administration and processing",
    "Configurable rules engine",
    "Business intelligence and real-time analytics",
    "Integration layer for partner systems and exchanges",
    "Promotion and configuration lifecycle management",
    "Provider data ingestion and enrichment",
    "Event-based, real-time API data distribution",
    "Support for prospective payment integrity integration",
    "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",
    "HealthRules Connector",
    "HealthRules Promote",
    "HealthRules Machine Readable Files Suite"
  ],
  "integrations": [
    "HealthEdge Source",
    "Wellframe",
    "GuidingCare",
    "Provider Data Management",
    "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": [
    "HITRUST CSF Certification"
  ],
  "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",
  "customers": [
    "HealthEdge Software"
  ],
  "user_reviews": [
    "Such a fantastic tool to use and more things to know.",
    "The one-step easy procedure. That is the best. Also, I am a prior user of Apria but HealthRules Payor is way much better that I now use it.",
    "Healthrules payor, you're a life save :)) Thank you so much.",
    "The integration you guys have is super easy. Healthrules payor has great operational efficiency. It saves time and the co-pay is less.",
    "The interface is much easier than anything else out there. Also, the compatibility with all the functions is great, the process has become much more easy to do the task.",
    "It's a comprehensive set of available services.",
    "Latest technology to help turn today's challenges into tomorrow's opportunities."
  ],
  "ratings": [
    "4.5/5 (G2)"
  ],
  "support_channels": [
    "email",
    "phone",
    "chat",
    "ticketing",
    "community",
    "24x7"
  ],
  "training_options": [
    "documentation",
    "webinars",
    "live_online",
    "onsite",
    "certification"
  ],
  "release_year": "2005",
  "integration_partners": [
    "TriZetto Facets",
    "TriZetto QNXT",
    "Veradigm Revenue Cycle Services",
    "Zelis",
    "NaviNet Open",
    "Simple Fractal",
    "Veradigm Payerpath",
    "intelliPath ePA"
  ],
  "id": "SW1457",
  "slug": "healthrules-payer",
  "type": "product",
  "version": "1.0",
  "last_updated": "2025-10-11",
  "links_json": {
    "self": "https://www.healthaidb.com/software/healthrules-payer.json"
  }
}