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U.S. Healthcare Payers’ Core Administrative Processing Solutions

U.S. Healthcare Payers’ Core Administrative Processing Solutions (CAPs) Reviews and Ratings

What are U.S. Healthcare Payers’ Core Administrative Processing Solutions?

Core administrative processing solutions (CAPS) are defined as software and services that support healthcare insurance administration and claims processing. These solutions historically reside at the center of payer architecture, serving as the system of record for claims and, in many cases, for member enrollment, premium billing and provider fee schedules. In the context of a member’s benefit plan, CAPS is responsible for processing claims to ensure accurate reimbursement and timely notification of payments and benefits to providers and members.

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Logo of TriZetto Facets Enterprise Core Administrative Platform

TriZetto Facets Enterprise Core Administrative Platform

By Cognizant

2.9
(4 Ratings)

Cognizant is focused on engineering modern businesses. The main problem it resolves is helping clients with modernization of their technology, reimagining their processes, and transforming their experiences to adapt to the rapidly changing world. Thus, the main goal of the company is to facilitate improvement in everyday life.

Cognizant helps companies modernize technology, reimagine processes and transform experiences so they stay ahead in a fast-changing world.

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Logo of TriZetto QNXT Enterprise Core Administration System

TriZetto QNXT Enterprise Core Administration System

By Cognizant

5
(1 Rating)

Cognizant is focused on engineering modern businesses. The main problem it resolves is helping clients with modernization of their technology, reimagining their processes, and transforming their experiences to adapt to the rapidly changing world. Thus, the main goal of the company is to facilitate improvement in everyday life.

Cognizant helps companies modernize technology, reimagine processes and transform experiences so they stay ahead in a fast-changing world.

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Logo of Accenture Health Administration BPO Services

Accenture Health Administration BPO Services

By Accenture

Accenture is a professional services corporation that has global capabilities in cloud, digital, and security domains. With proficiency and dexterity spanning across more than 40 sectors, Accenture provides a range of services such as Strategy and Consulting, Technology and Operations Services. It also features something named Accenture Song, powered by an extensive network of Advanced Technology and Intelligent Operations centers. It caters to clients in more than 120 countries, harnessing the capability of transforming changes into values to foster shared success.

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Aspen Web Portals

By HealthAxis Group

HealthAxis is a company specializing in the alteration of healthcare delivery in the United States through advanced technology. It has developed two key technologies known as AxisCore™, a core administrative processing system (CAPS), and AxisConnect™, a collection of business process services which include business process as a service (BPaaS), business process outsourcing (BPO), staff augmentation, and consulting capabilities. The primary objective of these technologies is to help payers, risk-bearing providers and third-party administrators in optimizing operations and enhancing engagement. The company's focus is on tackling prevalent challenges payers face, with the intent of improving both member and provider experiences, leading to more favourable outcomes.

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Logo of Burgess Source

Burgess Source

By Burgess

Burgess is a company that predominantly operates in the domains of healthcare, finance, and technology. The main business problem it works toward solving is Payment Accountability for American health insurers and ACOs. To achieve this, Burgess utilizes its unique cloud-based platform, Burgess Source. This platform amalgamates up-to-date regulatory data, claims pricing and editing, and real-time analytics tools. This cohesive approach allows its clients to make confident payments and informed business decisions. The company’s headquarters are located in Alexandria, VA.

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Logo of Core Stack 2.5

Core Stack 2.5

By HealthAxis Group

HealthAxis is a company specializing in the alteration of healthcare delivery in the United States through advanced technology. It has developed two key technologies known as AxisCore™, a core administrative processing system (CAPS), and AxisConnect™, a collection of business process services which include business process as a service (BPaaS), business process outsourcing (BPO), staff augmentation, and consulting capabilities. The primary objective of these technologies is to help payers, risk-bearing providers and third-party administrators in optimizing operations and enhancing engagement. The company's focus is on tackling prevalent challenges payers face, with the intent of improving both member and provider experiences, leading to more favourable outcomes.

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eHealthsuite

By Ram Technologies

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Enterprise Health Solution

By HM Health Solutions

enGen is a comprehensive technology platform focused on the health care sector. The firm develops and provides technological solutions for health plans and providers that significantly streamline operations and enhance members' experiences. With an adaptable service model, enGen ensures close attention and support to the clients precipitating their success. Primarily, the focus is on delivering high-quality products and services, intending to create a seamless customer journey on its technology platform. It aims to allow clients to focus on their primary responsibility - healthcare - by offering technology that simplifies administrative tasks.

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Enterprise System

By Wonderbox Technologies

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Healthcare Administration

By SS&C Technologies

SS&C is a global entity specializing in mission-critical, cloud-based software and solutions aimed at the financial and healthcare sectors. With operations scaling over 40 countries, SS&C works mainly with financial services and healthcare organizations. Its services encompass a spectrum of expertise and innovative approaches to cater to the specific needs of these sectors. It is an established entity with a substantial employee base.

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Healthcare Claims and Member Management Operations

By NASCO

NASCO focuses on creating products and solutions conducive to healthier outcomes. Rooted in healthcare expertise, the company aligns its strategies and talent to foster innovation. The aim is to provide customers with the tools to adapt and stay competitive in a fast-changing market environment. The innovation is driven by the development of new products, enhancement of capabilities, and increase in sharable services. Since November 2021, NASCO has been operating as an independent subsidiary of Blue Cross Blue Shield Of Michigan.

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Healthcare Core Administrative System

By Evolent Health

Evolent is a company that collaborates with health plans and providers with the aim to improve outcomes for individuals with complex health conditions. Its work spans across various medical specialties and primary care. The main objective is to align care plans with clinical evidence while ensuring seamless connectivity across providers and settings, managing members' objectives and preferences. Evolent serves a broad national clientele, including managed Medicaid, Medicare Advantage, and commercial health plans. By using resources like clinical pathways of high value, electronic decision support, and value-based payment models, the company is able to create a system that supports providers in delivering efficient, cost-effective care for their patients. Evolent was initially founded as Evolent Health in 2011 and has developed expertise in several key medical specialties. By 2023, the company plans to merge all its solutions and businesses under the brand "Evolent".

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Healthcare Solutions

By Vee Technologies

Vee Technologies, established in 2000, is a consulting and professional services organization based in New York City. The firm maintains technology hubs in Bangalore with service centers located in the Philippines, Salem, Hyderabad, and Chennai. Providing advanced technology solutions, Vee Technologies aids in process optimization, cash flow increase, cost reduction, and compliance maximization. The company caters to enterprises across the globe, enhancing productivity and achieving quality and cost outcomes. Vee Technologies is experienced in various sectors including Strategy & Consulting, Healthcare, Product Engineering, IT Services, Logistics, Media, Finance & Accounting, e-Governance, and LPO. The company offers a range of services such as Revenue Cycle Management, Health Information Management, Healthcare Analytics, Robotic Process Automation, Risk Adjustment Optimization, Legal Process Outsourcing, and Animation.

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HealthRules Answers

By HealthEdge

HealthEdge has an objective to foster a digital revolution in the healthcare sector. The company uses connecting business models between health plans, care providers, and patients with inclusive digital technology solutions. These efforts are aimed at supporting new operational models, reducing management costs and enhancing health outcomes. HealthEdge has an expanding range of products, like HealthRules Payer, Source, GuidingCare, and Wellframe, all aimed at transforming healthcare. Empowered by a global team of over 2,000 professionals, the focus is on introducing an innovative environment where the primary focus of healthcare is people.

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HealthRules CareManager

By HealthEdge

HealthEdge has an objective to foster a digital revolution in the healthcare sector. The company uses connecting business models between health plans, care providers, and patients with inclusive digital technology solutions. These efforts are aimed at supporting new operational models, reducing management costs and enhancing health outcomes. HealthEdge has an expanding range of products, like HealthRules Payer, Source, GuidingCare, and Wellframe, all aimed at transforming healthcare. Empowered by a global team of over 2,000 professionals, the focus is on introducing an innovative environment where the primary focus of healthcare is people.

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Logo of HealthRules Connector

HealthRules Connector

By HealthEdge

HealthEdge has an objective to foster a digital revolution in the healthcare sector. The company uses connecting business models between health plans, care providers, and patients with inclusive digital technology solutions. These efforts are aimed at supporting new operational models, reducing management costs and enhancing health outcomes. HealthEdge has an expanding range of products, like HealthRules Payer, Source, GuidingCare, and Wellframe, all aimed at transforming healthcare. Empowered by a global team of over 2,000 professionals, the focus is on introducing an innovative environment where the primary focus of healthcare is people.

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Logo of HealthRules Payor

HealthRules Payor

By HealthEdge

HealthEdge has an objective to foster a digital revolution in the healthcare sector. The company uses connecting business models between health plans, care providers, and patients with inclusive digital technology solutions. These efforts are aimed at supporting new operational models, reducing management costs and enhancing health outcomes. HealthEdge has an expanding range of products, like HealthRules Payer, Source, GuidingCare, and Wellframe, all aimed at transforming healthcare. Empowered by a global team of over 2,000 professionals, the focus is on introducing an innovative environment where the primary focus of healthcare is people.

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Logo of HealthRules Portal

HealthRules Portal

By HealthEdge

HealthEdge has an objective to foster a digital revolution in the healthcare sector. The company uses connecting business models between health plans, care providers, and patients with inclusive digital technology solutions. These efforts are aimed at supporting new operational models, reducing management costs and enhancing health outcomes. HealthEdge has an expanding range of products, like HealthRules Payer, Source, GuidingCare, and Wellframe, all aimed at transforming healthcare. Empowered by a global team of over 2,000 professionals, the focus is on introducing an innovative environment where the primary focus of healthcare is people.

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HEALTHsuite Mercato

By Ram Technologies

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Logo of HSP Payer Suite

HSP Payer Suite

By Health Solutions Plus

Healthcare Staffing Professionals (HSP) is a team comprised of recruitment specialists. The firm primarily focuses on finding suitable opportunities for individuals from the Clinical, Executive, Sales, and Information Technology sectors. The company operates by providing comprehensive assistance to candidates throughout the stages of job searching including the interviewing and hiring processes. On the other hand, HSP also serves employers by utilizing its internal resources in collaboration with its wide network of over 150 affiliate offices to connect employers with a large pool of potential candidates, ensuring speedy and efficient recruitment matches.

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Features of U.S. Healthcare Payers’ Core Administrative Processing Solutions

Updated January 2025

Mandatory Features:

  • Enroll and bill purchasers (i.e., employers, individuals and government entities).

  • Comply to industry regulations, such as HIPAA

  • Process and pay claims for nonmedical services such as vision and dental

  • Process and pay claims submitted for products, care and services that are delivered by healthcare providers

  • Support all API-enabled workflows and data formats — including EDI, commonly used for enrollment

  • Support and integrate with reporting and data and analytics software

  • Configure and manage health benefits

  • Integrate business process management and workflow automation

  • Enroll providers and manage fee schedules for claims processing

Gartner Research

Market Guide for U.S. Healthcare Payers’ Core Administrative Processing Solutions

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