Claims System Modernization

Optimize, Configure & Extend the Life of Legacy Claims Platforms

Alivia’s core expertise lies in optimizing and configuring industry-leading claims systems such as TriZetto® Facets® and QNXT™, as well as HealthEdge’s HealthRules® and Burgess Source®. We help health plans get the most out of these platforms by improving performance, scaling capacity, and supporting new lines of business, without requiring a full system replacement.

For plans still operating on aging or fragmented systems, we also manage migrations from legacy platforms such as AMISYS, Conduent HSP, and PowerMHS / PowerSTEPP into more modern, configurable environments.

Outcomes

Accelerated time to value from platform investments

Improved claims accuracy and operational predictability

Faster onboarding of new markets, lines of business, or state programs

Reduced IT and operational costs tied to manual workarounds

Increased agility to adapt to regulatory or benefit changes

Success Stories

Specialized Services

Platform Optimization & Configuration

  • Improves workflows, edits, and routing logic for speed and accuracy
  • Supports regulatory and compliance readiness through rules and process tuning

System Migrations, Upgrades & Testing

  • Transitions legacy platforms to Facets®, QNXT™, HealthRules®, or Burgess Source®
  • Manages data conversion, validation, and phased testing during cutover
  • Includes system assessments and upgrade planning

Business Line Enablement

  • Configures systems to support Medicaid, Medicare Advantage, and ACA markets
  • Ensures compliance with state, federal, and commercial requirements

Claims Platform Expertise

  • Hands-on experience with Facets®, QNXT™, HealthEdge’s HealthRules® and Burgess Source®, AMISYS, Conduent HSP, and PowerMHS / PowerSTEPP
  • Provides full-service configuration, optimization, and implementation support

Success Story

An Interview with the CIO of CommunityCare of Oklahoma (CCOK)

CCOK faced challenges with its outdated AMISYS adjudication platform and enterprise databases. Partnering with SourcEdge (now part of Alivia), they modernized systems by migrating to the cloud and updating their core platform.

Rusty Wyrick
SVP, Chief Technology & Transformation Officer

Success Story

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Frequently Asked Questions (FAQ)

Healthcare claims system modernization refers to the process of upgrading or replacing outdated legacy systems with modern, AI-driven solutions. These updates enable real-time claims processing, improve data integration, ensure compliance with healthcare regulations, and enhance operational efficiency across health plans and Medicaid agencies.

Legacy systems, such as older versions of AMISYS or PowerMHS™, are often inflexible, difficult to maintain, and incompatible with newer technologies. This can lead to delayed claims, increased administrative burden, compliance issues, and limited scalability. By modernizing healthcare IT infrastructure, organizations gain access to real-time analytics, improved interoperability, and better adaptability to evolving regulatory demands.

Claims system modernization offers several key advantages:

  • Increased efficiency in processing healthcare claims, reducing errors and manual workloads.
  • Enhanced regulatory compliance with CMS and HIPAA standards.
  • Improved data transparency and reporting through advanced analytics tools.
  • Better integration with fraud detection systems such as FWA Claims Manager™.
  • Scalability to handle growing claims volume without sacrificing speed or accuracy.

Alivia Analytics follows a comprehensive, phased approach:

  • Claims System Assessment – Evaluating existing legacy infrastructure for modernization readiness.
  • Custom Implementation Plan – Tailoring modernization to support organizational goals.
  • Advanced Technology Integration – Including machine learning, predictive analytics, and automated rules engines.
  • Seamless Platform Migration – Ensuring business continuity while upgrading core systems like QNXT™, Facets™, HealthRules™, and Conduent HSP™.
  • Ongoing Optimization & Support – Providing maintenance, user training, and continuous performance improvement.

Yes. Alivia Analytics has deep expertise in modernizing and optimizing widely used platforms such as:

  • TriZetto QNXT™ and Facets™
  • HealthEdge™ / HealthRules™
  • Conduent HSP™
  • AMISYS
  • PowerMHS™ / PowerSTEPP™

This includes re-platforming, process reengineering, and integrating new data streams and compliance logic into these systems.

AI plays a central role in healthcare claims system modernization by:

  • Automating routine tasks such as claims routing and adjudication.
  • Enhancing fraud, waste, and abuse detection before claims are paid.
  • Predicting anomalies and identifying outliers using historical claims data.
  • Improving decision-making through machine learning insights on provider behavior and utilization patterns.

Not with the right partner. Alivia Analytics emphasizes seamless integration and phased deployment to minimize disruption. Their modernization strategy includes backward compatibility, thorough testing environments, and real-time data synchronization to keep operations running smoothly throughout the transition.

Modern systems are built with compliance frameworks in mind, helping payers meet:

  • CMS program integrity requirements
  • HIPAA and HITECH standards
  • State-specific Medicaid modernization mandates

Alivia Analytics ensures that audit trails, regulatory reporting, and dispute resolution workflows are all embedded into the system.

Return on investment (ROI) includes:

  • Reduced administrative costs
  • Decreased error rates and claim rework
  • Faster payment cycles
  • Fewer penalties from compliance lapses
  • Improved provider satisfaction and plan reputation


These benefits can have long-term financial and operational impact, especially for large-scale commercial payers and managed care organizations.

“Alivia Analytics” and “Alivia 360” are trademarks of Alivia Analytics, LLC. All other trademarks, service marks, logos, and brand names referenced herein are the exclusive property of Alivia Analytics, LLC, unless otherwise stated.