In today’s rapidly evolving healthcare landscape, organizations require advanced solutions to navigate the complexities of operations, ranging from claims processing to ensuring regulatory compliance. With increasing demands for efficiency, accuracy, and adaptability, a core administration processing system plays a pivotal role in managing the intricate processes that are vital for healthcare and insurance organizations. This system needs to offer a comprehensive suite of functionalities that not only streamline administrative tasks but also support a variety of stakeholders.

In this blog post, we will explore the core features that a comprehensive healthcare management platform should offer according to a recent Gartner® report¹. The report highlighted nine mandatory features to look for when evaluating vendor offerings:

“Mandatory Features¹

1. Configure and manage health benefits
2. Enroll and bill purchasers (i.e., employers, individuals and government entities)
3. Enroll providers and manage fee schedules for claims processing
4. Process and pay claims submitted for products, care and services that are delivered by healthcare providers
5. Process and pay claims for non-medical services such as vision and dental
6. Support all API-enabled workflows and data formats — including EDI, commonly used for enrollment
7. Comply to industry regulations, such as HIPAA
8. Support and integrate with reporting and data and analytics software
9. Integrate business process management and workflow automation”

A core administration processing system must efficiently manage the above functions to ensure smooth operations. It must streamline health benefits configuration, enrollment, and billing, ensuring tailored coverage and accurate payments. Efficient provider enrollment and fee schedule management enable proper claims processing for both medical and non-medical services. Supporting API-enabled workflows and ensuring HIPAA compliance enhances integration and security. Additionally, integration with reporting tools aids decision-making, while business process management and workflow automation optimize efficiency and reduce errors.

Other factors to consider when evaluating a core administration processing system include:

• The availability and ease of use of self-service portals for members and providers. These portals should allow easy access to view, share, and manage relevant information, improving the overall user experience and reducing administrative overhead.
• Ensure that the system supports smooth prior authorization workflows, enabling providers to submit requests, track approvals, and receive timely responses.
• As healthcare systems evolve and new regulations or payment models emerge, the system should be adaptable and scalable to accommodate future needs without requiring significant overhauls.
• The system should have an intuitive interface for both users and administrators, with adequate support and training resources available to assist with onboarding and ongoing usage.
• Look for vendor stability, reliability, and responsiveness to ensure long-term success and continual improvement of the system.

By incorporating the mandatory features outlined above, along with additional evaluation factors, our solution, HEALTHsuite Advantage, ensures seamless operations, regulatory compliance, and operational efficiency.

Our fully integrated platform eliminates the need for third-party bolt-on solutions and is available in both SaaS and BPaaS models. It simplifies the management of health benefits, including enrollment, billing, and claims processing, while supporting API workflows and EDI data formats. Additionally, it offers seamless CMS integration with continuous updates to ensure ongoing compliance. To further enhance staff efficiency, we provide a self-service portal, eHealthsuite, for both members and providers.

Discover how our platform can support your organization’s success and drive innovation in healthcare management.

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¹ Gartner, Market Guide for U.S. Healthcare Payers’ Core Administrative Processing Solutions, Austynn Eubank, Connie Salgy, 18 December 2024
GARTNER is a registered trademark and service mark of Gartner, Inc. and/or its affiliates in the U.S. and internationally and is used herein with permission. All rights reserved.