Best Core Administrative Processing Systems Software

Zelis

Zelis is modernizing the business of healthcare by building something remarkable: a connected platform that bridges gaps in the financial system and aligns interests across healthcare insurers, providers, and consumers. Our platform is transforming the financial experience for more than 700 payers, including the top-5 national health plans, BCBS insurers, regional health plans, TPAs and self-insured employers, and millions of providers and members. We see across the financial experience to identify, optimize, and solve problems holistically with technology built by healthcare experts — driving real, measurable results for our clients.

Average Rating: 3.8/5.0

Total Reviews: 19

intelliPath ePA

Clinical Decision Support (CDS) system is a next-generation decision-support solution available to providers today.

Average Rating: 3.7/5.0

Total Reviews: 10

NaviNet Open

NaviNet Open Foundation consists of a series of layers: a platform, a set of network services, a suite of reimbursement-related and clinical applications, and a set of tools that customers can use to configure and customize the system.

Average Rating: 4.2/5.0

Total Reviews: 15

TriZetto QNXT

TriZetto offers consulting, IT, and business process solutions to streamline the deployment and adoption of technologies and improve operations for payers and providers in the health care industry. TriZetto solutions are designed to improve efficiency, accuracy, compliance, and results throughout the health care system.

Average Rating: 4.3/5.0

Total Reviews: 11

HealthRules Payer

Claims and benefits administration solution for health plans managing & processing. Provides the patented configuration feature.

Average Rating: 4.5/5.0

Total Reviews: 6

Veradigm Payerpath

Veradigm Payerpath® is an Internet-based suite of solutions that addresses every step in the reimbursement cycle.​

Average Rating: 4.1/5.0

Total Reviews: 12

Simple Fractal

Custom robotic process automation (RPA) solutions specializing in healthcare, finance, retail and professional services. Since our solutions are custom scripted, they are flexible, less fragile and more cost effective since there are no licensing fees from 3rd-party vendors. We use bots to: - Automate repetitive business functions that are tedious, error prone and don't contribute to employee satisfaction - Communicate between disparate systems - Integrate solutions with common business applications - e-mail, Excel, text, etc. - Create dynamic reports that "act" on the business intelligence data (send notifications, tasks, etc.) - and much more...

Average Rating: 4.9/5.0

Total Reviews: 16

PLEXIS Payer Platforms

Founded in 1996 and headquartered in Oregon, PLEXIS serves healthcare payer administrative organizations serving over 50 million people in all 50 states and 15 countries. PLEXIS provides enterprise core administration processing solutions to healthcare payers, specialty groups (dental, vision, radiology, etc.), TPAs, delegated risk groups (IPAs, ACOs, MSOs), international insurers, and government healthcare organizations/program administrators. PLEXIS Payer Platforms feature highly scalable, highly flexible and extremely automated core systems for the administration and management of health insurance and delegated risk operations, including group and individual policy administration, benefit plan administration, healthcare claims administration and auto-adjudication, provider and network management, payment contracts and fee schedules (both for providers and carriers), authorizations, capitation, premium billing and reporting.

Average Rating: 3.8/5.0

Total Reviews: 4

SHMS Payer Platform

Strategic Healthcare Management Systems (SHMS) enables health plans of all sizes reduce administrative overhead. SHMS has segment-specific products for healthcare payer organizations (claims/contracting/adjudication, provider networks, enrollment/member management, risk adjustment, etc.) as well as powerful EDI tools to support automated electronic interaction between vendors.

Average Rating: 5.0/5.0

Total Reviews: 2

Accenture Health Experience Platform

End-to-end efficiency accelerates customer acquisition, boosts retention and promotes long-term growth prospects for health payer organisations.

Average Rating: 3.5/5.0

Total Reviews: 1

Assurance Reimbursement Management

An analytics-driven claims and remittance management solution for healthcare providers who want to automate workflows, improve resource utilization, and accelerate cash flow.

Average Rating: 5.0/5.0

Total Reviews: 1

CAQH EnrollHub

CAQH, a non-profit alliance, is the leader in creating shared initiatives to streamline the business of healthcare.

Total Reviews: 1

Codoxo

Codoxo's Forensic AI Platform is an advanced artificial intelligence solution designed to help healthcare organizations detect and prevent fraud, waste, and abuse (FWA within their payment systems. By analyzing vast amounts of claims data, the platform identifies suspicious activities and provides actionable insights, enabling healthcare payers and agencies to safeguard their financial resources and ensure the delivery of high-quality care. Key Features and Functionality: - Comprehensive Data Analysis: Utilizes self-learning AI to examine claims data, detecting entities that may intentionally or unintentionally contribute to financial waste. - Cross-Claim Connectivity: Builds connections across various claim types, including professional, facility, pharmacy, and dental claims, to deliver holistic insights. - Proactive Provider Education: Shifts payment integrity efforts upstream by providing insights to providers before claims are submitted, reducing denials, appeals, and resubmissions. - Automated Audit Workflows: Streamlines the audit process by automating workflows and digitizing medical record retrieval, enhancing efficiency and compliance. - Integrated Case Management: Offers a unified platform for Special Investigation Units (SIU to detect emerging fraud schemes and manage investigations effectively. Primary Value and Problem Solved: The Forensic AI Platform addresses the critical challenge of financial losses in the healthcare system due to FWA. By enabling early detection and prevention of suspicious activities, it helps organizations achieve significant cost savings—averaging over $60 per member per year—and improves payment accuracy to 99%. Additionally, the platform fosters stronger provider relationships by reducing administrative burdens and minimizing provider abrasion through proactive education and streamlined processes.

Average Rating: 4.5/5.0

Total Reviews: 1

Veradigm Revenue Cycle Services

Veradigm founded in 1986, is an integrated data systems and services company that combines data-driven clinical insights with actionable tools to help healthcare stakeholders improve the quality, efficiency, and value of healthcare delivery—these stakeholders include biopharma, health plans, healthcare providers, network partners, and most importantly, the patients they serve. Veradigm delivers a unique combination of point-of-care clinical and financial solutions, a commitment to open interoperability, a large and diverse healthcare provider footprint, along with industry proven expert insights. As a result, Veradigm attracts leaders in healthcare, technology, and innovation, seeking to work with us to deliver next-generation insights and solutions to the benefit the healthcare ecosystem with the objective being to improve healthcare quality while lowering the cost of healthcare. The Veradigm Network features proven platforms and solutions along with a dynamic community of companies providing advanced insights, technology, and data-driven solutions, all working together to transform healthcare and advance value, insightfully.

Average Rating: 4.1/5.0

Total Reviews: 16

Assured Health

Assured is the first AI-native provider network management platform built for healthcare organizations that cannot afford to wait months to get providers seeing patients and generating revenue. NCQA-certified as a Credentials Verification Organization (CVO) and backed by $6M in seed funding led by First Round Capital, Assured serves digital health companies, health systems, provider groups, and health plans nationwide. Organizations, including Houston Methodist, Tono Health, and Blossom Health, run their provider operations on Assured. Where traditional credentialing vendors depend on offshore teams, spreadsheets, and manual data entry, Assured deploys AI agents that verify credentials across 2,000+ primary sources in parallel, auto-generate and submit applications directly to payor portals and state licensing boards, and flag sanctions within 24 hours. The platform handles end-to-end credentialing, multi-state licensing across all 50 states, payor enrollment with automated roster management, and continuous compliance monitoring from a single system. Renewals initiate automatically 60 days before expiration. Integrations with CAQH, NPPES, PECOS, and plug-and-play APIs for your ATS, EMR, or Salesforce mean no rip-and-replace required. Credentialing delays cost healthcare organizations thousands in lost revenue per provider per month. Assured cuts that timeline from 60+ days to 48 hours. Payor enrollments close 30% faster with the highest first-pass approval rates in the industry. Sanctions get caught within 24 hours, not weeks. Teams go live in under 72 hours, see ROI within the first month, and reclaim 60+ hours per week previously buried in admin work. If your providers are sitting in a backlog, you are bleeding revenue. Assured stops the bleed.

Average Rating: 4.5/5.0

Total Reviews: 1