Top 10 Best Health Insurance Claims Management Software of 2026

TriZetto Facets is a leading enterprise platform for health insurance payers, providing end-to-end core administrative processing including claims adjudication, enrollment, benefits configuration, provider management, and capitation. It processes billions of claims annually with high accuracy, supporting compliance with HIPAA, EDI standards, and value-based care models. Facets offers modular scalability, advanced analytics via QNXT tools, and seamless integrations with third-party systems to optimize payer operations and reduce administrative costs.

HealthEdge HealthRules Payer is a comprehensive core administrative processing system designed specifically for health insurance payers, automating claims adjudication, enrollment, benefits administration, and provider management. Its powerful, patented HealthRules engine enables highly configurable business rules to handle complex claims processing for medical, pharmacy, and dental services with sub-second response times. The platform supports scalability for high-volume environments and integrates seamlessly with external systems for end-to-end payer operations.

ZeOmega Jiva is a comprehensive enterprise platform for health plans, specializing in claims management alongside population health, care coordination, and member engagement. It features a robust rules-based adjudication engine that supports high-volume claims processing, auto-adjudication rates exceeding 90%, and integration with EDI standards for seamless payer-provider interactions. The solution leverages AI and analytics for fraud detection, denial management, and predictive insights to optimize claims workflows and reduce operational costs.

Vitech V3 is a cloud-native policy administration system (PAS) from ViTech Solutions, providing comprehensive end-to-end management for health insurance, including automated claims adjudication, provider management, and payer workflows. It leverages a configurable rules engine to handle complex claims processing, ensuring compliance with regulations like HIPAA and supporting high-volume transactions. Designed for scalability, V3 integrates seamlessly with third-party systems for real-time data exchange and reporting.

Inovalon QNXT is a robust, enterprise-grade claims management platform primarily designed for health insurance payers, with a strong focus on Medicare Advantage and commercial claims processing. It provides end-to-end functionality including claims adjudication, provider management, enrollment, and reporting, leveraging a configurable rules engine to handle complex regulatory requirements. Widely used by large health plans, QNXT excels in high-volume transaction processing and integrates with Inovalon's broader data ecosystem for analytics and quality insights.

Edifecs offers a robust healthcare interoperability platform specializing in claims management for health insurers and payers. It excels in EDI transaction processing, claims editing, validation, adjudication, and compliance with standards like HIPAA, X12, and NPI. The solution streamlines high-volume claims workflows, reduces errors, and supports real-time analytics for operational efficiency.

Availity is a comprehensive healthcare network platform designed for revenue cycle management, enabling providers to submit claims, verify eligibility, track status, and process remittances electronically with thousands of payers. It streamlines claims management through advanced editing, scrubbing, and analytics to reduce denials and accelerate payments. The platform integrates with EHRs and practice management systems, supporting high-volume processing across hospitals, clinics, and billing services.

Cotiviti is a leading provider of payment accuracy and analytics solutions tailored for health insurance payers, focusing on optimizing claims management processes. The platform offers tools for claims editing, auditing, fraud detection, and overpayment recovery using AI and advanced analytics to ensure accurate reimbursements. It helps payers reduce financial leakage, improve compliance, and enhance operational efficiency in high-volume claims environments.

Change Healthcare provides a robust claims management platform that automates the submission, adjudication, and payment posting of health insurance claims for providers and payers. It leverages AI-driven editing and extensive payer connectivity to minimize denials and accelerate reimbursements. The solution integrates seamlessly with EHRs, practice management systems, and clearinghouses, handling billions of transactions annually.

Milliman ClaimVantage is a robust claims administration platform tailored for health insurance payers, third-party administrators (TPAs), and self-funded employers. It automates claims adjudication with high-speed processing, configurable rules engines, and advanced editing capabilities to handle complex health claims efficiently. Leveraging Milliman's actuarial expertise and data resources, it supports compliance, fraud detection, and integration with core payer systems for streamlined operations.