MCRA Members

With over 18 years of experience serving U.S. health plans, Simplify Healthcare partners with U.S. health plans to modernize the core operational backbone of payer organizations—benefits, provider, claims, and member engagement—through a unified, AI-enabled platform.

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Their services help plans execute regulatory and market changes faster and with lower risk, while reducing operational friction across traditionally siloed teams. They support health plans across Commercial Group, ACA, Medicare, Medicaid, and dual-eligible lines of business with solutions that address configuration complexity and improve data integrity, compliance readiness,

cost takeout, and member experience at scale.

 

Today, more than 70 health plans rely on Simplify Healthcare’s purpose-built payer platforms across Commercial, ACA, Medicare, Medicaid, and dual eligible lines of business. The value they deliver is practical and measurable:

• A clean, trusted data foundation for automation and AI

• Solutions improve benefits and provider data quality and workflow consistency, enabling plans to apply automation and AI safely and effectively across operations.

• Operational scalability without adding headcount

• Across payer organizations, their platforms are used to drive measurable cost efficiencies—reducing manual rework, minimizing claims leakage, lowering vendor dependency, and enabling teams to scale operations without proportional increases in cost or staffing.

• Configuration accuracy before claims and service failures occur

• They address errors upstream—during benefits, provider, and claims configuration—rather than after they surface as rework, appeals, or compliance exposure.

• Regulatory change without disruption

 

Health plans use Simplify Healthcare to implement CMS, state, and market-driven changes without last-minute firefighting, downstream claims issues, or member complaints.  Faster launches with fewer dependencies on core system vendors. Plans reduce reliance on long development cycles and vendor backlogs by configuring, validating, and testing changes independently of core platform release timelines. In short, health plans work with Simplify Healthcare when the priority is execution certainty, compliance confidence, and operational efficiency—not experimentation.

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What Makes Simplify Healthcare Unique
 

Simplify Healthcare is differentiated by their depth of execution in payer operations, not just advisory or point technologies.

 

A key differentiator is the connected benefits and provider journey. Simplify Healthcare enables alignment between benefit design, provider networks, and claims logic on a shared data foundation—reducing mismatches that typically lead to downstream claims issues, member confusion, and provider abrasion.

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Simplify Healthcare is unique because they:

• Understand payer reality: They solutions are built around how health plans actually operate—across enrollment, benefits, provider data, claims, and member communications.

• Reduce downstream risk: They address issues upstream in configuration and data that often surface later as compliance failures, member abrasion, or claims fallout.

• Operate as a neutral layer: They integrate with leading core systems rather than forcing rip-and-replace decisions.

• Deliver measurable outcomes: Clients see tangible improvements in accuracy, turnaround time, and regulatory readiness.

• Scale across lines of business: Their platform supports multiple markets without requiring separate tools or duplicated effort. Their platform capabilities have been recognized by leading industry analysts such as IDC and Gartner, including recognition for leadership in benefits configuration solutions and provider data management.

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Managed Care Segments / Lines of Business Served
 

• Medicare

• Medicaid

• Commercial

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Products/Services

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• Benefits Configuration and Management (Benefits1™)

• Centralized benefits modeling and configuration across markets

• Faster product launches and regulatory updates

• Reduced configuration errors and rework

• Provider Data and Network Operations (Provider1™)

• End-to-end provider lifecycle management

• Unified platform spanning data ingestion, normalization, credentialing, contracting, network maintenance, and downstream interoperability

• Claims Configuration and Validation (Claims1™)

• Code set and claims logic configuration

• Pre- and post-adjudication validation

• Reduced claims leakage and reprocessing

• Integrate with leading core systems (Facets®, QNext™, top 5 core admin systems, and homegrown, etc.

• AI-Driven Member and Operations Engagement (Xperience1™)

• Intelligent automation for inquiries and workflows

• Reduced benefit inquiry call volumes and resolution times

• Improved operational efficiency without increasing headcount

• Document Generation and Compliance Support (Simplify Docs™)

• Automated generation of regulated payer communications

• Version control, audit readiness, and turnaround time reduction