Top 10 Best Healthcare Claims Adjudication Software of 2026

TriZetto Facets, developed by Cognizant, is a leading enterprise platform for healthcare payers, specializing in end-to-end claims adjudication and administration. It automates claims processing with high accuracy rates, supports complex pricing rules, and integrates seamlessly with provider networks, member enrollment, and benefits management. Widely used by major health plans, it handles massive volumes while ensuring HIPAA compliance and regulatory adherence.

HealthRules Payer by HealthEdge is a robust, enterprise-grade claims adjudication platform designed for health payers to automate and streamline the processing of medical and pharmacy claims. It features a highly configurable rules engine that enables payers to implement complex business logic without extensive coding, supporting auto-adjudication, provider reimbursement, and compliance with industry standards like HIPAA and NCQA. The platform scales to handle high-volume claims processing in real-time, integrating with core administrative systems for end-to-end payer operations.

QNXT by Inovalon is a robust enterprise-grade claims adjudication platform tailored for health plans, TPAs, and payers in the healthcare industry. It streamlines the entire claims lifecycle, from intake and editing to auto-adjudication, pricing, and payment, supporting both real-time and batch processing. The system excels in handling high-volume claims with HIPAA-compliant workflows, advanced rules configuration, and seamless integration with EHRs, provider portals, and other core systems.

Edifecs ClaimXten is a robust healthcare claims adjudication platform designed for payers to automate and optimize the end-to-end claims processing workflow. It provides real-time editing, auditing, and adjudication using advanced rules engines compliant with EDI X12, HIPAA, and NCQA standards. The solution includes fraud detection, analytics, and integration capabilities to reduce payment errors and accelerate reimbursements.

Jiva by Zeomega is a comprehensive healthcare platform with robust claims adjudication capabilities tailored for payers and health plans. It automates the entire claims lifecycle, from editing and adjudication to payment and reporting, using advanced rule engines and AI-driven analytics. The solution integrates seamlessly with care management and population health tools, ensuring compliance with HIPAA and other regulations while minimizing manual intervention.

Availity is a comprehensive health information network platform that connects healthcare providers with payers for streamlined claims submission, status tracking, eligibility verification, and electronic remittance advice (ERA). It functions as a clearinghouse facilitating the claims adjudication process by enabling real-time data exchange and automation of administrative workflows. Integrated with major EHR and practice management systems, Availity helps reduce denials and speed up reimbursements through its vast network covering over 3,000 payers.

Waystar is a comprehensive revenue cycle management (RCM) platform designed for healthcare providers, focusing on claims processing, submission, and optimization to support efficient adjudication. It features advanced claims scrubbing, real-time eligibility verification, denial prevention, and payment acceleration through AI-driven insights and extensive payer integrations. The software helps organizations achieve high clean claims rates, reduce denials, and streamline reimbursements across hospitals and physician practices.

V3Core from Vitech is a comprehensive core administration platform tailored for insurance carriers, with strong capabilities in healthcare claims adjudication through automated processing, rules-based engines, and integration with provider systems. It handles claim intake, validation, pricing, adjudication, and payment while supporting compliance with healthcare regulations like HIPAA. The solution excels in high-volume environments, offering real-time analytics and fraud detection to streamline operations for health insurers.

OptumClaims, from Optum (optum.com), is an enterprise-grade healthcare claims adjudication platform that automates the processing, editing, and adjudication of medical claims for payers and providers. It leverages advanced rules engines, AI-driven analytics, and real-time validation to reduce denials, ensure regulatory compliance, and accelerate reimbursements. The solution integrates with EHRs, practice management systems, and payer portals to streamline end-to-end claims workflows.

Athenahealth is a cloud-based healthcare platform offering integrated electronic health records (EHR), practice management, and revenue cycle management (RCM) solutions tailored for ambulatory practices. Its athenaCollector module specializes in healthcare claims adjudication by automating claims scrubbing, submission, eligibility verification, denial management, and payment posting to minimize errors and accelerate reimbursements. The system leverages AI-driven analytics for predictive denial prevention and seamless payer connectivity.