Top 10 Best Healthcare Payer Administration Software of 2026

TriZetto Facets is a leading enterprise-grade healthcare payer administration platform that streamlines core operations for health plans, including claims processing, member enrollment, provider management, and premium billing. It supports end-to-end payer workflows with advanced automation, rules-based adjudication, and scalability for high-volume transactions. As the market leader, it powers a significant portion of U.S. commercial claims, offering modular flexibility for customization across payer types like managed care and government programs.

HealthRules Payer by HealthEdge is a robust core administrative processing system (core APS) for healthcare payers, handling end-to-end operations including claims adjudication, member enrollment, premium billing, provider management, and capitation. It leverages a powerful, configurable rules engine to support complex business logic across multiple lines of business like Medicare, Medicaid, and commercial plans. The platform is designed for scalability, with cloud-native architecture enabling real-time processing and value-based care models.

TriZetto QNXT is a comprehensive core administrative platform designed for healthcare payers, handling critical functions like claims processing, member enrollment, premium billing, provider management, and utilization review. It supports multiple lines of business including commercial, Medicare, Medicaid, and supports compliance with HIPAA and other regulations. With its scalable, modular architecture, QNXT enables payers to configure complex benefit plans and integrate with third-party systems for efficient operations.

Jiva by Zeomega is a comprehensive core administrative platform for healthcare payers, handling end-to-end processes like claims adjudication, member enrollment, provider management, and benefits administration. It integrates advanced analytics, AI-driven automation, and population health management to enhance operational efficiency and member engagement. Designed for scalability, Jiva supports both on-premise and cloud deployments, making it suitable for mid-to-large health plans navigating complex regulatory environments.

V3locity by ViTech is a modern, cloud-native policy administration system (PAS) tailored for insurance carriers, including healthcare payers, handling enrollment, premium billing, claims adjudication, and member management. It features a low-code configuration engine called Valence, enabling rapid product development and deployment without extensive coding. The platform supports complex health payer workflows like HIPAA compliance, provider networks, and real-time analytics, making it suitable for replacing legacy systems.

InFinicity by iStream Health is a cloud-based healthcare payer administration platform that handles core functions like claims adjudication, member enrollment, provider management, benefits configuration, and capitation processing. It supports various payer models including health plans, third-party administrators (TPAs), and self-insured groups with a focus on scalability and regulatory compliance. The solution emphasizes a no-code rules engine for customizing workflows and real-time analytics for operational efficiency.

Edifecs Payer Cloud is a comprehensive SaaS platform tailored for healthcare payers, enabling efficient management of core administrative functions such as claims processing, enrollment, provider network management, and payment integrity. It excels in handling EDI transactions (e.g., 837/835) with advanced transformation tools like Xengine, while supporting modern FHIR APIs for interoperability and real-time data exchange. The solution incorporates AI-driven analytics for risk adjustment, fraud detection, and compliance with evolving regulations like HIPAA and CMS requirements.

The Optum Payer Platform is a comprehensive, enterprise-grade healthcare payer administration software suite from Optum, a UnitedHealth Group company, designed to manage core payer operations including claims processing, member enrollment, provider contracting, benefits administration, and payment integrity. It leverages AI, machine learning, and Optum's vast proprietary healthcare data to optimize workflows, reduce administrative costs, and support value-based care initiatives. The platform is cloud-native, scalable, and integrates with EHRs, pharmacies, and other systems for end-to-end payer efficiency.

Change Healthcare Payer Solutions offers a comprehensive, cloud-based platform for healthcare payers, handling core functions like claims adjudication, member enrollment, provider management, and payment integrity. It integrates advanced analytics, AI-driven automation, and interoperability tools to streamline operations and improve accuracy across high-volume environments. The suite supports both legacy modernization and innovative services such as fraud detection and predictive modeling, making it suitable for large-scale payer operations.

The Gainwell Advantage Platform is a comprehensive healthcare payer administration solution that handles core functions including claims adjudication, member enrollment, provider network management, and benefits administration. It supports both commercial health plans and government payers with scalable, modular architecture for high-volume processing. Emphasizing regulatory compliance and integration with legacy systems, it enables efficient operations and data-driven decision-making for large-scale payers.