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Core Administrative Processing System (CAPS)HealthOS CAPS: Claims Management Software
HealthOS CAPS: Claims Management Software
Built on AxisCore
With an evolved look and feel rooted in the proven foundation of AxisCore, HealthOS CAPS is claims management software and the core administrative processing system (CAPS) for health plans, TPAs, and risk-bearing provider groups. By unifying six operational areas and letting Aipass™, our AI engine, automate the routine work, it frees your team to focus where human judgment actually matters.
HITRUSTSOC 2 Type IIHL7 FHIR R4EDI 837, 835, 270, 271
Claims QueuePrior AuthMembersProviders
Claims MTD8,447
Clean Rate93.6%
In Review412
CLM-4421 · $2,480.00Auto-adjudicated
PaidCLM-4419 · $860.50Coordination of benefits
ReviewCLM-9920Duplicate billing detected
HoldAIAipass™ auto-adjudicated 214 clean claims this hour and flagged 3 for coordination-of-benefits review.
Running on the AxisCore engine, upgraded for HealthOS
Workspace Overview
What Is HealthOS CAPS?
HealthOS CAPS is HealthAxis’ core administrative processing system (CAPS) and claims management software. It is the single workspace at the center of HealthOS where claims adjudication, eligibility, provider management, and network operations run on one shared data core, with Aipass™ embedded to clear repetitive work before it reaches your team. Whether you’re a health plan, a TPA managing delegated business, or a risk-bearing provider group, CAPS gives you one system built around how core administration actually works.
A Shared Data Core
Every other HealthOS workspace reads and writes to the same live core. No exports, no nightly syncs.
Aipass™ Does the First Pass
Aipass™, HealthAxis’ AI engine, clears clean work itself. Exceptions land on a reviewer’s desk with the reasoning already attached.
Platform Foundation
Evolved from the foundation of AxisCore
AxisCore, the proven CAPS. AxisCore is HealthAxis’ established claims administration engine. It orchestrates claims, eligibility, and benefit rules as one source of truth, not a database of separate tables.
HealthOS CAPS, the AI-native CAPS. HealthOS CAPS carries the AxisCore engine and its security model forward as a cloud-native workspace. It shares one data core with Plan, Provider, Member, Enrollment, and Sentinel.
AxisCore — The Proven CAPS
A unified, cloud-native core administrative processing system engineered to handle modern health plan volume. Not a database. An orchestration engine.
HealthOS CAPS — The AI-Native CAPS
The same orchestration engine, now on HealthOS's shared data core, with Aipass™ embedded across every workflow and Plan, Provider, Member, Enrollment, and Sentinel connected around it.
Cloud-Native Architecture
AxisCore's foundation, rebuilt on microservices for zero-downtime scaling across all six HealthOS workspaces.
Immutable Security
The same enterprise-grade encryption and SOC 2 Type II compliance built into the core layer, now the security baseline for the entire platform.
Aipass™ Embedded Intelligence
Agentic AI woven directly into the orchestration engine, clearing clean work and routing exceptions to a reviewer in real time.
Claims Management Software Built Around the Full Claim
HealthOS CAPS handles a claim from the moment it arrives to the moment it is paid and logged. These are the jobs it does, in the words buyers search.
Claims Adjudication
Aipass™ checks each claim against eligibility, benefits, and policy and clinical edits before anyone has to. Clean claims clear. Anything ambiguous goes to a reviewer with the reasoning already attached.
Claims Processing Automation
Clean, criteria-matched work clears itself, so your team works the exceptions, not the whole queue. The same automation runs for authorizations, eligibility checks, and provider updates. For prior authorization in depth, see HealthOS Plan.
Healthcare Claims Processing Software That Speaks EDI
CAPS works with EDI 837, 835, 270, and 271 transactions and the HL7 FHIR R4 standard.
Benefits Administration Software on the Same Record
Eligibility and benefits sit on the same record as the claim, so a claim is checked against the member’s current coverage with no separate lookup.
Inside CAPS
Six Modules. Every One Built Around a Job, Not a Database Table.
Pick a module to see what your team actually touches inside it.
Member Administration
Member 360 turns five systems' worth of history, eligibility, claims, complaints, and billing into one record, so nobody has to ask a member to repeat themselves.
MembersMember 360 ProfileCare ManagementMember BillingComplaints & Grievances
Active Members47,855
New This Month312
Eligibility Holds14
Member #88213Eligibility confirmed
ActiveMember #88250Documentation required
HoldEnrollment batch · 312Daily eligibility feed
ProcessedClinical
Claims and authorizations run through Aipass™'s clinical and policy edits automatically. The clean ones clear. The rest land on a reviewer's desk with the reasoning already attached.
AuthorizationsClaimsBenefitsScheduler
Claims MTD8,502
Clean Rate94.1%
In Review388
CLM-4421 · $2,480.00Auto-adjudicated
PaidCLM-4419 · $860.50Coordination of benefits
ReviewCLM-9920Duplicate billing detected
HoldProvider Administration
Provider 360, onboarding, and credentialing stay in sync automatically, so your directory doesn't quietly go stale the way most do.
ProvidersProvider 360 ProfileProvider OnboardingCredentialingProvider PerformanceProvider Directory
Network Providers3,482
Pending Credential27
Attestations Due18
Dr. AlvarezCredentialing complete
ActiveDirectory ListingAddress mismatch flagged
ReviewGroup NPI 10442Onboarding in progress
In ProgressNetwork & Contracts
Contracts, vendors, and service codes live in the same console as claims, so a rate change on Monday is live in adjudication by Tuesday.
Networks & IPAsContractsVendorsService Codes
Active Contracts1,842
Expiring (90d)28
Active Networks3
Contract CN-2291Renewal needed
ReviewVendor V-118Performance on target
ActiveService Code UpdateFee schedule published
ProcessedPlan Operations
DOFR, billing, and customer service run on the same data as everything else, so a billing question doesn't require calling three departments to answer.
Health Plans & BillingDOFRDeterminantGroup AdminCustomer Service
Premiums Collected$2.14M
Outstanding$28,410
Open Service Cases2
DOFR Route CN-2291Auto-routed to TPA
ProcessedGroup Admin UpdatePlan year rollover
CompletedService Case SC-4021Billing inquiry
OpenSystem Administration
Roles, workflows, and configuration are centralized, with an audit log that remembers everything so your team doesn't have to reconstruct it later.
User ManagementRoles & AccessWorkflow AdminSystem ConfigAudit LogSSO / IAM
Active Users214
Roles Configured18
Audit Events (24h)1,204
Role UpdateClaims Reviewer II
ApprovedSSO SessionNew IAM policy applied
ActiveAudit ExportQ2 compliance package
ReadyHow Work Moves
What Happens in the Seconds After a Claim Hits CAPS.
This is claims processing automation in practice. The same path runs for authorizations, eligibility checks, and provider updates. Most of it, your team never sees.
- Intake
A claim, authorization, or eligibility request lands in CAPS from a provider, a member, or a batch feed.
- Aipass™ Score
Aipass™ checks it against eligibility, benefits, and policy and clinical edits before anyone has to.
- Auto-Clear or Route
Clean, criteria-matched work clears itself. Anything ambiguous gets routed, not buried.
- Reviewer Action
A reviewer sees Aipass™'s reasoning already attached and makes the call in seconds, not minutes.
- Paid & Logged
The outcome updates the member, provider, and plan record everywhere at once, with a full trail behind it.
The Intelligence Layer, Inside CAPS
Aipass™ Runs Inside Every CAPS Queue, Not Next to It.
Aipass™ is HealthAxis’ AI engine. It scores every claim, authorization, and eligibility check the second it enters CAPS. What’s clean clears itself. What’s ambiguous lands on a reviewer’s desk with the reasoning already attached.
Learn more about Aipass™Live decision intelligence● Active
Claim CLM-4419 · $860.50Flagged01 / Review
Analysis completeEligibility verified · Benefits matched · Secondary coverage detected: coordination of benefits required before payment.
RecommendationRoute to COB reviewer with the secondary payer record attached.
Confidence 96%
Why HealthOS CAPS?
The Numbers Behind the Console.
What health plans, TPAs, and provider groups typically see after moving core administration onto CAPS.
70%+Faster Cycle Time
91%First Contact Resolution
50%Fewer Manual Touches
20–40%Operational Excellence
Why CAPS
What Changes When Claims Administration Runs on CAPS.
The difference shows up in the parts of the job nobody wants to do twice.
| The Old Way | On CAPS |
|---|---|
| Your team re-keys the same member and provider data into three different systems, every time. | Member 360 and Provider 360 are the single source. Every module reads from the same record. |
| Clean claims sit in the same queue as the complicated ones, waiting their turn. | Aipass™ clears clean claims and routine authorizations the moment they qualify, no waiting in line. |
| Credentialing status, contract terms, and directory listings live in trackers that never quite agree. | Provider, network, and contract data update in one place and show up everywhere else instantly. |
| Audit season means reconstructing who did what, and when, from memory and email threads. | Every automated and manual action logs itself. Audit prep starts from a record, not a reconstruction. |
| Adding a new workflow means a new implementation project, a new vendor, a new login. | CAPS already shares a data core with Plan, Provider, Member, Enrollment, and Sentinel. Adding one is a configuration, not a project. |
Security & Compliance
Built to the Standards Your Compliance Team Already Holds You To.
Role-based access control, encryption in transit and at rest, and a complete audit log across every module — the same baseline for every HealthOS workspace.
HITRUSTSOC 2 Type IIHL7 FHIR R4EDI 837 · 835 · 270 · 271
FAQ
Frequently Asked Questions.
HealthOS CAPS is HealthAxis’ core administrative processing system (CAPS) for health plans, TPAs, and risk-bearing provider groups. It is claims management software that runs claims, eligibility, benefits, and authorizations on the same live data core as the other HealthOS workspaces.
A core administrative processing system is the software a health plan runs its day-to-day administration on. It holds member, provider and benefit data, and processes claims from intake to payment.
Claims management software tracks and processes claims from the moment they arrive until they are paid or denied. In HealthOS CAPS, this includes intake, adjudication, review, payment, and an audit trail.
Each claim is scored by Aipass™ when it arrives. Clean claims are adjudicated and cleared automatically. Claims with a question, such as coordination of benefits or a possible duplicate, go to a reviewer with the evidence attached.
Yes. Aipass™ scores and routes work as it enters each queue, so staff handle the exceptions, not every claim. The same flow applies to authorizations, eligibility checks, and provider updates.
No. HealthOS CAPS carries forward the AxisCore engine and its security model, rebuilt as an AI-native workspace that shares one data core with the other five HealthOS workspaces.
Yes. HealthOS CAPS works as a standalone workspace and can connect to the rest of HealthOS later without re-implementation.
Aipass™ scores and routes work when it enters a queue, auto-clears clean transactions, and sends ambiguous ones to a reviewer with the supporting evidence attached.
HealthOS CAPS aligns with HIPAA, HITRUST, SOC 2 Type II and CMS requirements. It uses role-based access control, encryption in transit and at rest, and a complete audit log.
Last updated:
One Console, One Suite
Six Workspaces. One Record.
Every HealthOS workspace reads and writes to the same core. Start with CAPS, connect the rest whenever your team is ready.
Get Started
See HealthOS CAPS in the context of your operations.
Walk through your claims flow with the team that runs it.
