HealthRules Edge configuration that keeps auto-adjudication high.
We configure, integrate and support HealthEdge HealthRules Edge, the core claims engine formerly called HealthRules Payer. That covers migrations from older claims systems, benefit configuration, the CMS-0057-F data feeds and HealthRules analysts when the bench is short.
Bain Capital (Apr 2025); UST HealthProof merger (Sep 2025)
release watch
Renamed HealthRules Edge
AWS scalability benchmark10 Mar 2026
connects with
in short·15-second read
HealthRules Edge is HealthEdge's cloud-native core claims engine for health plans.
It used to be HealthRules Payer. Cohash migrates plans onto it from older claims systems and configures benefit plans and pricing. We build the integrations and the data feeds behind the CMS-0057-F APIs, track why claims fall out of auto-adjudication and supply HealthRules configuration analysts and developers.
you probably need this if
Auto-adjudication dropped after the plan-year benefit changes went in, and nobody can say why.
The legacy claims system is being retired and conversion hasn't been rehearsed.
CMS-0057-F feeds need HealthRules data and the field mapping hasn't started.
Pend-reason analysis ranked by claim volume with causes
Conversion runbook with claim re-run comparison results
Benefit and pricing regression pack from your claims
+ 2 more documents
who does it
HealthRules benefit and pricing configuration analystHealthRules integration developerClaims data conversion engineer
platforms
healthedge · release timeline
08 Apr 2025Bain Capital investment Bain Capital agreed to acquire HealthEdge. source ↗
04 Sep 2025UST HealthProof merger HealthEdge and UST HealthProof announced a merger. source ↗
10 Mar 2026AWS scalability benchmark In a benchmark, HealthEdge says, one HealthRules instance on AWS supported more than 40 million members. source ↗
today · Oct 22, 2026
no date yetRenamed HealthRules EdgeHealthRules Payer is now HealthRules Edge. HealthEdge describes it as its core claims engine.source ↗
the story · healthedge healthrules edge estate
From the first call to a setup your own team can run.
Here's what usually prompts a call about your HealthEdge HealthRules Edge estate, what we do about it and in which order, and where you end up.
01 · where it hurts02 · what we change03 · how it runs04 · where you end up
incident board · healthedge healthrules edge estate3 open
openAuto-adjudication dropped after the plan-year benefit changes went in, and nobody can say why.
recurringThe legacy claims system is being retired and conversion hasn't been rehearsed.
blockedCMS-0057-F feeds need HealthRules data and the field mapping hasn't started.
exposure
Migration onto HealthRules EdgeBenefit and pricing configurationAuto-adjudication analysisIntegrations and CMS-0057-F feedsAI feature evaluationSpecialist staffing
startrehearsehandover
Data and configuration review
Claim re-run
Conversion or fix plan
Go-live and handover
we are here
ready to hand over
Claims are flowing through auto-adjudication again.
Go-live happens with conversion rehearsed and payment differences explained.
Pend-reason analysis ranked by claim volume with causes
Conversion runbook with claim re-run comparison results
chapter 01 · where it hurts
Why teams reach out
Auto-adjudication dropped after the plan-year benefit changes went in, and nobody can say why.
The legacy claims system is being retired and conversion hasn't been rehearsed.
CMS-0057-F feeds need HealthRules data and the field mapping hasn't started.
chapter 02 · what we change
How we solve it
Migration onto HealthRules Edge
Benefit and pricing configuration
Auto-adjudication analysis
Integrations and CMS-0057-F feeds
AI feature evaluation
Specialist staffing
chapter 03 · how it runs
Our approach
Data and configuration review
Claim re-run
Conversion or fix plan
Go-live and handover
chapter 04 · where you end up
What changes
Claims are flowing through auto-adjudication again.
Go-live happens with conversion rehearsed and payment differences explained.
Pend-reason analysis ranked by claim volume with causes
Conversion runbook with claim re-run comparison results
what we do
Our HealthEdge HealthRules Edge work
6 kinds of HealthEdge HealthRules Edge work, each run by engineers who have done it on live tenants.
Benefit, provider and member data moved from a legacy claims system, with conversion rehearsed and claims re-run to compare results before go-live.
Benefit plans, pricing and workflow configured for new plan years and products, tested against your own claims.
Pend reasons ranked by volume, traced to configuration or data causes, and fixed in priority order.
Interfaces to care management, payment integrity, CRM and EDI partners, plus data feeds for the Provider Access, Payer-to-Payer and Prior Authorization APIs.
A written scope from HealthEdge for HealthRules Edge AI and the Agentic Platform, a baseline on your claims and review rules before anything is switched on.
HealthRules configuration analysts, integration developers and testers, onsite in the US or from nearshore and offshore teams across time zones, within your data access rules.
capability 01 / 06in production
Migration onto HealthRules Edge
Benefit, provider and member data moved from a legacy claims system, with conversion rehearsed and claims re-run to compare results before go-live.
Interfaces to care management, payment integrity, CRM and EDI partners, plus data feeds for the Provider Access, Payer-to-Payer and Prior Authorization APIs.
A written scope from HealthEdge for HealthRules Edge AI and the Agentic Platform, a baseline on your claims and review rules before anything is switched on.
HealthRules configuration analysts, integration developers and testers, onsite in the US or from nearshore and offshore teams across time zones, within your data access rules.
HealthEdge HealthRules Edge situations we walk into
We pieced these together from HealthEdge HealthRules Edge situations that come up a lot. They're patterns. You won't find a specific client in them.
case file 01
Auto-adjudication fell after the January benefit load
composite · not a client story
Beforethe situation
After the new plan-year benefits were loaded into HealthRules, more claims started pending for manual review. Examiners are working overtime and the cause isn't clear.
What we dothe work
We rank pend reasons by volume since January, trace the top ones to configuration or data changes and fix them in a lower environment with test claims. Fixes are promoted in order of claims affected.
Afterwhere you end up
Claims are flowing through auto-adjudication again. And the benefit load has a regression check now.
case file 02
Retiring a legacy claims system onto HealthRules Edge
composite · not a client story
Beforethe situation
A regional plan is replacing a legacy claims system with HealthRules Edge. Provider data disagrees from one source to the next, and nobody has re-run a single claim on the new configuration.
What we dothe work
Provider and member data gets profiled and fixed at source where possible. Conversion happens in rehearsals. Then we run a sample of historical claims through HealthRules Edge and explain every difference before go-live.
Afterwhere you end up
Go-live happens with conversion rehearsed and payment differences explained.
approach
How a HealthEdge HealthRules Edge engagement runs
We don't start a step until the last one has produced something you can check.
step 01
Data and configuration review
We document benefit plans, pricing, provider and member data, interfaces and the pend reasons that send claims to manual work.
step 02
Claim re-run
A sample of real claims runs through the new or changed configuration, and results are compared with the legacy system or the prior year.
step 03
Conversion or fix plan
We use the comparison to plan the migration, or the configuration fixes, and put them in order of claim volume affected.
step 04
Go-live and handover
We support go-live and the first claim cycles, then leave regression packs, interface runbooks and a pend-reason dashboard.
ai on healthedge healthrules edge
Where AI fits on HealthEdge HealthRules Edge, and where it needs guardrails.
HealthEdge now sells HealthRules Edge, which used to be HealthRules Payer. It has HealthRules Edge AI built into claims workflows to support auto-adjudication, plus a HealthEdge Agentic Platform that places agents across health plan workflows. Its public pages give few details or dates, so an engineering team should ask for specifics before planning around them.
AI agentasks for data or an action
Scoped identityonly the access it needs
MCP serverthe one door into the platform
Logged, approveda person signs off on writes
HealthEdge HealthRules Edgedoes the work
HealthEdge doesn't currently publish an official MCP server, so agents should connect through the APIs and integration services HealthEdge supports for your contract. For us that means a dedicated service identity with read-only access by default. We log the calls, and a person approves any claim or member record change first.
HealthRules Edge AI in claims
HealthEdge describes HealthRules Edge AI as AI built into claims workflows to support auto-adjudication. For us the first step, before switching anything on, is recording your current auto-adjudication rate and the pend reasons that send claims to manual work. Then any change gets measured on your own claims.
HealthEdge Agentic Platform
There's also what HealthEdge calls an Agentic Platform, putting agents across health plan workflows. The public pages don't say what's available or how it's licensed. We'd ask HealthEdge for written scope first. Then we'd set review rules and access per agent you turn on.
Configuration and upgrade work with AI
AI can draft documentation for benefit plan, pricing and workflow configuration, and it can turn recent claims into regression cases for each release. For us, an engineer checks every draft against the configuration itself.
Data for CMS-0057-F and analytics
For the Provider Access, Payer-to-Payer and Prior Authorization APIs, AI can propose how HealthRules data maps to the FHIR resources behind them and point out fields that have no clear source. For us, each mapping gets tested against real member records before go-live.
Claims and enrollment arrive by EDI and API, and HealthRules Edge adjudicates them. Pended claims go to examiners. The same data feeds the CMS-0057-F APIs and the analytics platform.
What a HealthEdge HealthRules Edge engagement leaves behind
These are working documents, written against your configuration, so your team can run them without us.
report01
Pend-reason analysis ranked by claim volume with causes
yours to keep
runbook02
Conversion runbook with claim re-run comparison results
yours to keep
tests03
Benefit and pricing regression pack from your claims
yours to keep
inventory04
HealthRules-to-FHIR mapping for the CMS-0057-F APIs
yours to keep
inventory05
Interface inventory with owner and failure handling per feed
yours to keep
talent and delivery · healthedge healthrules edge
Certified engineers, wherever you need them.
Some clients want a project team, some want a couple of engineers on theirs. Either works. Onsite, nearshore or offshore, with handovers across time zones that keep things moving.
Onsite
Engineers at your sites in the US
Nearshore
Overlapping hours with US teams
Offshore
Overnight progress on your backlog
All time zones
Coverage handed over across time zones
24-hour coverage · US Central time
OnsiteUS business hours
Nearshoreoverlapping US hours
Offshoreovernight progress
Combinedhandover, not hand-off
00:0006:0012:0018:0000:00
roles we staff
HealthRules benefit and pricing configuration analyst
HealthRules integration developer
Claims data conversion engineer
HealthRules claims test analyst
FHIR API developer for CMS-0057-F
due diligence · healthedge healthrules edge
Questions to ask any partner, including us.
Put these to anyone bidding on your HealthEdge HealthRules Edge work. The ones who've done it answer differently from the ones who've read about it.
Q1
Which pend reasons send the most claims to manual review today?
Auto-adjudication rates drop for specific reasons. Rank those by volume and you know where the fixes matter.
Q2
How will you prove the new configuration pays like the old system?
Finance and compliance want evidence before go-live, and a claim re-run comparison is the evidence they'll accept.
Q3
What exactly does HealthEdge's AI include under our contract?
HealthEdge's public pages say little about HealthRules Edge AI or its Agentic Platform. Get the scope in writing before you plan anything around it.
Q4
How will provider data be cleaned before conversion?
Bad provider data turns into pricing errors after go-live. Fix it at source, or you'll be cleaning it up again and again.
Q5
How will the CMS-0057-F feeds be tested against real members?
The APIs are due on 1 January 2027. Synthetic test data won't show the gaps that real member records do.
01Is HealthRules Edge the same product as HealthRules Payer?
Yes. HealthEdge says HealthRules Edge is the core claims engine that used to be HealthRules Payer. The sister products got new names too, so GuidingCare is Clinical Edge now and Source is Payment Accuracy Edge.
02How long does a migration onto HealthRules Edge take?
It depends on how many products and plan years you convert, how clean provider and member data is and how many interfaces need rebuilding. We size it after a data and interface inventory and a sample claim re-run.
03Who owns HealthEdge?
The deal came first. Bain Capital agreed to acquire HealthEdge in April 2025, and in September 2025 HealthEdge and UST HealthProof announced their merger.
04Do your people hold a HealthRules certification?
HealthEdge doesn't run a public HealthRules certification program. We screen analysts on which configuration areas and migrations they've actually worked on.
05Can you build the CMS-0057-F feeds from HealthRules data?
Yes. We map the HealthRules data each API needs and flag fields with no clear source. Then we test against real member records ahead of the 1 January 2027 deadline.
services
Related services
Projects on HealthEdge HealthRules Edge usually end up touching one of these, so they're worth a look.
