Core administrative operations are a vital component of healthcare plan and payer organizations. However, with the increasing complexity of delivery and implementation options, the legacy Core Administration Processing Solution (CAPS) falls short. The key core administrative functions include benefits administration, claims processing, member enrollment, claims payment and adjustments, and product management for benefits and product lines. While the legacy system provides a stable environment that can be customized to fit the customer’s needs, the changing dynamics of industry compliance, regulatory requirements, emergence of value-based care and payment reforms necessitate the industry to seek new providers in the core administrative domain.

Payers engage with members across various touchpoints, cutting through multiple lines of businesses and transactions using a wide range of payer platform modules enabled by cutting-edge technologies. By adopting an advanced cloud-based core administration solution, payers can better handle the operational functions with enhanced efficiency and a more robust technological stack.

This compendium provides comprehensive and fact-based snapshots of 14 healthcare core administration platforms providers. Each profile specifies the provider’s position on Everest Group’s PEAK Matrix® and offers an insightful analysis of its capabilities. The compendium will enable providers to benchmark their capabilities against their peers, while buyers will be able to assess the providers based on their desired set of capabilities.

Scope

• Industry: healthcare
• Geography: global
• Services: healthcare core administration platforms
• The assessment is based on Everest Group’s annual RFI process for the calendar year 2022, interactions with leading healthcare providers offering healthcare core administration platforms, client reference checks, and an ongoing analysis of the US healthcare CAPS market

Contents

In this report, we:

• Assess 14 healthcare cloud-based core administration platforms providers based on their capabilities and market success
• Provide enterprise sourcing considerations, highlighting providers’ key strengths and limitations

Membership(s)

Healthcare Payer and Provider Information Technology

Sourcing and Vendor Management