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Payer Claims & Administration Platforms Payer Claims & Administration Platforms
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Payer Claims & Administration Platforms
2022 Vendor Guide

author - Joe VanDeGraaff
Author
Joe VanDeGraaff
author - Jennifer Hickenlooper
Author
Jennifer Hickenlooper
author - Ruirui Sun
Author
Ruirui Sun
 
September 8, 2022 | Read Time: 7  minutes

Current Time Inside Cache Tag Helper: 10/2/2022 8:57:51 PM and Model.reportId = 3004

Value-based care models have created widespread recognition among health plans that flexible technology is a must, while the need to be more member-centric and digitally focused is driving a desire for better integration between claims platforms and other payer HIT applications. This vendor guide is intended as a simple starting point for health plans and TPAs investigating payer claims and administration platforms. The guide is limited only to vendors with commercial software solutions (services firms are not covered) and includes all vendors known to KLAS as of July 2022.

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Claims & Administration Platforms: Segment Overview

  • Claims and administration platforms enable health plans to complete core operational and administrative functions, such as claims processing, member enrollment, and product line management (benefit and plan offerings).
  • The market has been around for a long time; the majority of commercial solutions were acquired by the vendors that currently maintain them.
  • Though some health plans use internal or homegrown efforts to support their claims processing and member enrollment, use of commercial solutions has of late become the more common trend.
  • The number of available offerings is growing, with some newer software solutions coming to market and with some existing vendors now providing new delivery models, such as SaaS and BPaaS.

Overview of Payer Claims & Administration Vendors

Below are brief summaries of how each vendor currently positions their payer claims and administration solution for the US market. The summaries are based on vendor-provided and publicly available information and do not represent any KLAS-validated performance data or other findings.

Current customer feedback and KLAS performance data on measured vendors in this segment can be found on the KLAS website.
vendor profile lables 1
vendor profile lables 2

advalent profile

Advalent Core Claims Administration Solution
Offers a cloud-based solution and claims it integrates with other vendors’ products. Vendor shows differentiation in their codified smart contracts, which allow clients to define rules that govern payments. Based on those rules, compliant legal documents are then automatically generated and kept up-to-date.

advantasure profile

Advantasure Core Administration Solutions
Vendor claims that their offerings are low maintenance and that they reduce errors and manual processing. Vendor claims that clients have achieved very high auto-adjudication rates and a big reduction in total operating costs. Product is said to be specifically built for the government healthcare market.

athenahealth profile

athenahealth athenaIDX Financial Risk Manager
Product said to be used by delegated risk organizations, ACOs, payers, and others. Vendor positions offering as managing complex payment structures and being integrated with their hospital and clinic financial billing solutions. Also offered as standalone solution that can integrate with other vendors’ solutions.

cedar gate technologies profile

Cedar Gate Technologies Payment Technology
Vendor positions their offering as a platform for value-based care and payer-provider collaboration. Vendor’s capitation and bundles administration applications feature self-service tools that are said to increase the efficiency of financial managers by automating preauthorization, claims adjudication, payment reconciliation, and other processes that are specific to alternative payment models.

cognizant profile

Cognizant TriZetto
Vendor claims their three core administration TriZetto product lines—Facet, QNXT, and QicLink—cover over 50% of lives in US. Facet and QNXT can be used to administer multiple lines of business, provide a broad set of modules, and integrate with other TriZetto products. QicLink is built specifically for TPAs.

conduent profile

Conduent HSP Core Claims Administration
Product features a flexible user-definable claims adjudication engine, which is said to support medical, dental, vision, and specialty health benefits administration for multiple business lines. Vendor states the product optimizes claims auto-adjudication rates that exceed industry-recommended standards.

eis group profile

EIS Group ClaimCore
With a primary initial focus on the dental market, vendor has experience in various nonhealthcare insurance industries and is relatively new to the healthcare market. Positions themselves as providing speed in deployment and digital transformation, with the particular angle of SaaS solutions and deployment.

engen profile

enGen Enterprise Health Solutions (HM Health Solutions)
Formerly known as HM Health Solutions, enGen works with health plans (primarily Blues plans) to provide value-based care solutions for payer and provider organizations, claiming to serve more than 11 million members nationwide. Vendor is positioned as providing a platform and products to improve members’ health and streamline complex operations.

epic profile

Epic Tapestry
Vendor offers their core payer administration product, named Tapestry, to provider-owned health plans and managed care organizations that are using other HIT products from Epic. Vendor describes the solution as being fully integrated with other Epic revenue cycle and clinical products.

healthaxis profile

HealthAxis HxPro
Vendor’s current focus is said to be primarily on government lines of business, particularly Medicare Advantage and Special Needs Plans. Current product offering—HxPro—was launched in last five years; technology can be paired with BPaaS services or used by health plans’ internal operations. Vendor claims their core administration solutions streamline the customer experience.

healthedge profile

HealthEdge HealthRules Payor
Vendor positions their patented HealthRules Language as delivering a new approach to configuration, claims processing, and transparency. Vendor claims that customers regularly achieve high rates of auto-adjudication, accuracy, and growth by reducing the time it takes to create benefits plans and lines of business.

mphasis profile

Mphasis Javelina (Eldorado)
Vendor serves multiple different industries with 35+ years in healthcare. Formerly known as Eldorado, the platform utilizes vendor’s Front2Back framework. Vendor emphasizes a customer-centric approach to helping clients transition to value-based care and meet regulatory requirements. Vendor positions the product as affordable.

nasco profile

NASCO Core Administration Solutions
Recognized as being associated with and dedicated to the network of Blues plans; ownership recently changed to Blue Cross Blue Shield of Michigan. Vendor offers various payer solutions covering areas, including enrollment, claims adjudication, and member/provider servicing. High on the list of vendor promotion is the solutions’ HITRUST certification for information security.

oracel profile

Oracle Insurance Claims Administration Cloud Service
A cross-industry vendor that provides solutions to both providers and health plans. Positions their product as the most flexible, adaptable solution in the market with the ability to support all lines of health insurance. Vendor claims to be the only large-scale cloud provider that builds the entire stack in-house.

pega profile

Pega Smart Claims Engine
Vendor positions product as providing modular flexibility and automation to manage payer claims operations. Vendor claims differentiation via its Guided Pend Resolution module, which is said to offer curated navigation for claims being resolved. Said to be used by some of the largest health plans.

plexis profile

PLEXIS Healthcare Systems PLEXIS Payer Platforms
The product is SQL based and processed on the Windows operating system. The platform is claimed to offer ease of configuration and affordability for high ROI. Vendor claims the product to be interoperable with other business apps through their web services-based APIs (referred to as Passport Connectivity service).

ram profile

RAM HEALTHsuite Advantage
Vendor positions their software and services offering as tailored to the needs of Medicare Advantage, Managed Medicaid, and Special Needs Plans. Vendor is said to provide flexible deployment options for HEALTHsuite Advantage, including SaaS, on premises, and BPaaS delivery models.

skygen profile

SKYGEN Core Administration Solutions
Serving primarily dental and vision payer organizations, vendor positions themselves as providing specialty payers with technology and services to deliver specialty benefits via flexible deployment options. Recent product developments are said to include technologies to streamline interactions between payers, providers, members, brokers, and other constituents, such as mobile apps and portals.

ss&c profile

SS&C Health Core Claims Administration 
A cross-industry vendor that provides solutions to both healthcare providers and payers. The core platform is said to meet administrative requirements for any line of business. Platform is part of the vendor’s BPO offerings and is offered in the form of BPaaS.

vba profile

VBA VBASoftware
Core claims solution with a customer base largely made up of TPAs but expanding into the medical market. Vendor positions configuration and flexibility as core benefits of their product. Self-service portals are also a focus.

viveka profile

Viveka Health Claims Administration
New healthcare-specific vendor emerging in the claims administration market. Claims to offer eligibility, enrollment, and claims solutions to multiple different markets. Current positioning includes reference to communication apps focused on member experience.

wlt software profile

WLT Software MediClaims
Vendor claims to work one-on-one with clients to create personalized systems that fit customers’ needs. The solution is a native Windows application, and the database is said to partner with Oracle’s solution.


About KLAS

Driven by a mission to improve healthcare, KLAS publishes research data intended to help provider and payer organizations make clear decisions and to act as a catalyst to help vendors improve their products and services.

Current Time Inside Cache Tag Helper: 10/2/2022 8:57:51 PM and Model.reportId = 3004

Claims & Administration Platforms: Segment Overview

  • Claims and administration platforms enable health plans to complete core operational and administrative functions, such as claims processing, member enrollment, and product line management (benefit and plan offerings).
  • The market has been around for a long time; the majority of commercial solutions were acquired by the vendors that currently maintain them.
  • Though some health plans use internal or homegrown efforts to support their claims processing and member enrollment, use of commercial solutions has of late become the more common trend.
  • The number of available offerings is growing, with some newer software solutions coming to market and with some existing vendors now providing new delivery models, such as SaaS and BPaaS.

Overview of Payer Claims & Administration Vendors

Below are brief summaries of how each vendor currently positions their payer claims and administration solution for the US market. The summaries are based on vendor-provided and publicly available information and do not represent any KLAS-validated performance data or other findings.

Current customer feedback and KLAS performance data on measured vendors in this segment can be found on the KLAS website.
vendor profile lables 1
vendor profile lables 2

advalent profile

Advalent Core Claims Administration Solution
Offers a cloud-based solution and claims it integrates with other vendors’ products. Vendor shows differentiation in their codified smart contracts, which allow clients to define rules that govern payments. Based on those rules, compliant legal documents are then automatically generated and kept up-to-date.

advantasure profile

Advantasure Core Administration Solutions
Vendor claims that their offerings are low maintenance and that they reduce errors and manual processing. Vendor claims that clients have achieved very high auto-adjudication rates and a big reduction in total operating costs. Product is said to be specifically built for the government healthcare market.

athenahealth profile

athenahealth athenaIDX Financial Risk Manager
Product said to be used by delegated risk organizations, ACOs, payers, and others. Vendor positions offering as managing complex payment structures and being integrated with their hospital and clinic financial billing solutions. Also offered as standalone solution that can integrate with other vendors’ solutions.

cedar gate technologies profile

Cedar Gate Technologies Payment Technology
Vendor positions their offering as a platform for value-based care and payer-provider collaboration. Vendor’s capitation and bundles administration applications feature self-service tools that are said to increase the efficiency of financial managers by automating preauthorization, claims adjudication, payment reconciliation, and other processes that are specific to alternative payment models.

cognizant profile

Cognizant TriZetto
Vendor claims their three core administration TriZetto product lines—Facet, QNXT, and QicLink—cover over 50% of lives in US. Facet and QNXT can be used to administer multiple lines of business, provide a broad set of modules, and integrate with other TriZetto products. QicLink is built specifically for TPAs.

conduent profile

Conduent HSP Core Claims Administration
Product features a flexible user-definable claims adjudication engine, which is said to support medical, dental, vision, and specialty health benefits administration for multiple business lines. Vendor states the product optimizes claims auto-adjudication rates that exceed industry-recommended standards.

eis group profile

EIS Group ClaimCore
With a primary initial focus on the dental market, vendor has experience in various nonhealthcare insurance industries and is relatively new to the healthcare market. Positions themselves as providing speed in deployment and digital transformation, with the particular angle of SaaS solutions and deployment.

engen profile

enGen Enterprise Health Solutions (HM Health Solutions)
Formerly known as HM Health Solutions, enGen works with health plans (primarily Blues plans) to provide value-based care solutions for payer and provider organizations, claiming to serve more than 11 million members nationwide. Vendor is positioned as providing a platform and products to improve members’ health and streamline complex operations.

epic profile

Epic Tapestry
Vendor offers their core payer administration product, named Tapestry, to provider-owned health plans and managed care organizations that are using other HIT products from Epic. Vendor describes the solution as being fully integrated with other Epic revenue cycle and clinical products.

healthaxis profile

HealthAxis HxPro
Vendor’s current focus is said to be primarily on government lines of business, particularly Medicare Advantage and Special Needs Plans. Current product offering—HxPro—was launched in last five years; technology can be paired with BPaaS services or used by health plans’ internal operations. Vendor claims their core administration solutions streamline the customer experience.

healthedge profile

HealthEdge HealthRules Payor
Vendor positions their patented HealthRules Language as delivering a new approach to configuration, claims processing, and transparency. Vendor claims that customers regularly achieve high rates of auto-adjudication, accuracy, and growth by reducing the time it takes to create benefits plans and lines of business.

mphasis profile

Mphasis Javelina (Eldorado)
Vendor serves multiple different industries with 35+ years in healthcare. Formerly known as Eldorado, the platform utilizes vendor’s Front2Back framework. Vendor emphasizes a customer-centric approach to helping clients transition to value-based care and meet regulatory requirements. Vendor positions the product as affordable.

nasco profile

NASCO Core Administration Solutions
Recognized as being associated with and dedicated to the network of Blues plans; ownership recently changed to Blue Cross Blue Shield of Michigan. Vendor offers various payer solutions covering areas, including enrollment, claims adjudication, and member/provider servicing. High on the list of vendor promotion is the solutions’ HITRUST certification for information security.

oracel profile

Oracle Insurance Claims Administration Cloud Service
A cross-industry vendor that provides solutions to both providers and health plans. Positions their product as the most flexible, adaptable solution in the market with the ability to support all lines of health insurance. Vendor claims to be the only large-scale cloud provider that builds the entire stack in-house.

pega profile

Pega Smart Claims Engine
Vendor positions product as providing modular flexibility and automation to manage payer claims operations. Vendor claims differentiation via its Guided Pend Resolution module, which is said to offer curated navigation for claims being resolved. Said to be used by some of the largest health plans.

plexis profile

PLEXIS Healthcare Systems PLEXIS Payer Platforms
The product is SQL based and processed on the Windows operating system. The platform is claimed to offer ease of configuration and affordability for high ROI. Vendor claims the product to be interoperable with other business apps through their web services-based APIs (referred to as Passport Connectivity service).

ram profile

RAM HEALTHsuite Advantage
Vendor positions their software and services offering as tailored to the needs of Medicare Advantage, Managed Medicaid, and Special Needs Plans. Vendor is said to provide flexible deployment options for HEALTHsuite Advantage, including SaaS, on premises, and BPaaS delivery models.

skygen profile

SKYGEN Core Administration Solutions
Serving primarily dental and vision payer organizations, vendor positions themselves as providing specialty payers with technology and services to deliver specialty benefits via flexible deployment options. Recent product developments are said to include technologies to streamline interactions between payers, providers, members, brokers, and other constituents, such as mobile apps and portals.

ss&c profile

SS&C Health Core Claims Administration 
A cross-industry vendor that provides solutions to both healthcare providers and payers. The core platform is said to meet administrative requirements for any line of business. Platform is part of the vendor’s BPO offerings and is offered in the form of BPaaS.

vba profile

VBA VBASoftware
Core claims solution with a customer base largely made up of TPAs but expanding into the medical market. Vendor positions configuration and flexibility as core benefits of their product. Self-service portals are also a focus.

viveka profile

Viveka Health Claims Administration
New healthcare-specific vendor emerging in the claims administration market. Claims to offer eligibility, enrollment, and claims solutions to multiple different markets. Current positioning includes reference to communication apps focused on member experience.

wlt software profile

WLT Software MediClaims
Vendor claims to work one-on-one with clients to create personalized systems that fit customers’ needs. The solution is a native Windows application, and the database is said to partner with Oracle’s solution.


About KLAS

Driven by a mission to improve healthcare, KLAS publishes research data intended to help provider and payer organizations make clear decisions and to act as a catalyst to help vendors improve their products and services.

author - Carlisa Cramer
Writer
Carlisa Cramer
author - Jessica Bonnett
Designer
Jessica Bonnett
author - Andrew Wright
Project Manager
Andrew Wright
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This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price. Please see the KLAS DATA USE POLICY for information regarding use of this report. © 2022 KLAS Research, LLC. All Rights Reserved. NOTE: Performance scores may change significantly when including newly interviewed provider organizations, especially when added to a smaller sample size like in emerging markets with a small number of live clients. The findings presented are not meant to be conclusive data for an entire client base.