Healthcare Payer Software for Modern Health Plans
Helios® by Elligint Health is healthcare payer software that unifies care management, utilization management, and analytics for Medicare Advantage, Medicaid, and commercial health plans. Trusted with more than 13 million covered lives across all 50 states, Helios helps your teams act earlier on risk, move authorizations faster, and stay audit-ready as mandates change.
What Is Healthcare Payer Software?
Healthcare payer software is the technology health plans use to manage member care, review and authorize services, track quality and cost, and meet regulatory requirements across every line of business. The strongest platforms connect care management, utilization management, and analytics on one member record instead of stitching together separate point tools.
Helios is healthcare payer software built on that model. Helios CM and Helios UM run on one cloud-based, FHIR-native platform, with Advanced Analytics and the Helios Partner Ecosystem built in. Elligint Health was formed through the merger of VirtualHealth and HealthEC, bringing the Helios platform and HealthEC’s population health analytics together under one name.
The Pressures Health Plans Face — and How Helios Responds
Payers are being asked to do more with less: tighter regulatory timelines, rising medical costs, higher quality expectations, and teams that can’t simply add headcount. Helios is built to take friction out of each one.
Regulatory Mandates That Keep Moving
CMS-0057-F has raised the bar on prior authorization turnaround, denial transparency, and FHIR-based data exchange. Helios UM automates authorization intake, triage, and determinations, with built-in compliance tracking aligned with CMS-0057-F and an audit trail on every decision.
Star Ratings and Quality Performance
Quality bonuses depend on closing gaps across large populations. Helios tracks HEDIS® measures, Star Ratings, and care gaps in unified dashboards, and its population health capabilities are NCQA pre-validated.
Administrative Cost and Staffing Limits
Manual reviews and disconnected systems inflate admin spend. Helios replaces redundant tools with configurable, automated workflows across care and utilization management. One care coordination organization using Helios improved care team efficiency by 85%.
Rising Medical Costs and Rising-Risk Members
Cost trends rarely announce themselves early. Helios uses predictive risk stratification to surface rising-risk and rising-cost members, then routes them straight into care management workflows so teams can intervene before costs escalate.
Healthcare Payer Software for Every Line of Business
Helios ships with out-of-the-box templates for Medicare Advantage, Medicaid, and commercial programs, and it is 90% configurable to your contracts, policies, and workflows.
Medicare Advantage
Configure workflows to your plan-specific model of care and quality programs. Care teams manage care gaps, transitional care management (TCM), chronic care management (CCM), and screening programs through automated triggers. Helios also supports Medicare-specific authorization rules and day-limit management while capturing the data needed for NCQA, ODAG, and CDAG reporting.
Medicaid Managed Care / MLTSS
Coordinate medical, behavioral, and social services under state-specific rules, including HCBS, long-term services and supports, and programs for members with intellectual and developmental disabilities (IDD). Helios tracks eligibility history, alerts care teams before members approach disenrollment, and embeds SDOH assessments and community resource referrals. Learn more about our Medicaid managed care capabilities and MLTSS programs.
Commercial
Automate utilization review, run disease management programs for high-cost conditions, and coordinate care across provider networks. Commercial teams use the same configurable workflows as government lines, so nothing runs on a separate system.
Plan Growth & New Lines of Business
Whether you’re entering a new market, adding a line of business, or providing care and utilization management services on behalf of other health plans, Helios configures to each new contract, policy, and workflow on the platform you already run. When Medicaid funding and federal programs shift, you change your configuration, not your system. As your plan grows, Helios grows with you.
Other Organizations We Serve
Value-Based Care Organizations
Align quality, cost, and performance across ACOs, clinically integrated networks, and value-based contracts.
MLTSS Programs
Coordinate HCBS services, long-term supports, and state waiver requirements in one system of record.
Government & Community Programs
Support Medicaid managed care, public health initiatives, and community-based care coordination.
One Platform Built for Payer Performance
Helios modules work independently or together, so you can start with care management or utilization management and add capabilities as your needs change.
Helios CM
Care management software with 360° member views, automated care plans, risk stratification, and disease management programs, plus built-in member messaging (Helios Text®) and telehealth (Helios Visit®).
Helios UM
Utilization management software that automates prior authorizations, appeals, and grievances, with a provider portal for authorization intake and MCG and InterQual® criteria built into review workflows.
Advanced Analytics
Population health management insights that surface risk, quality gaps, PMPM trends, and medical loss ratio performance across clinical, claims, and financial data.
Helios Partner Ecosystem
Pre-integrated partners such as Itiliti Health for AI-enabled prior authorization, and findhelp and Unite Us for SDOH, extend Helios without adding another system.
Need claims validation, eligibility checks, or remittance processing? E-Connect Clearinghouse has supported payers and providers for 14+ years.
Proven Results for Health Plans
INTERLINK Health used Helios UM and Helios CM to earn URAC Accreditation in Utilization Management for its Cancer CARE for Life program. That’s the kind of third-party validation health plans look for before trusting a partner with delegated review. Evaluating healthcare payer software? Browse the full Resource Hub for case studies and expert perspectives.
Related resources
Healthcare Payer Software FAQs
Look for one member record shared across care management, utilization management, and analytics; workflows you can configure by line of business; FHIR-native interoperability; built-in compliance tracking; and third-party validation such as HITRUST, NCQA, or URAC. Helios by Elligint Health delivers all five on one cloud-based platform supporting more than 13 million covered lives.
Yes. Helios includes out-of-the-box templates for Medicare Advantage, Medicaid, and commercial programs. It is 90% configurable, so each plan, contract, and program can follow its own rules on the same platform.
CMS-0057-F sets prior authorization timelines, denial-reason, reporting, and FHIR API requirements for Medicare Advantage organizations, Medicaid and CHIP managed care plans, and other impacted payers. Helios UM is built to help health plans meet those requirements with automated prior authorization workflows, compliance tracking aligned with CMS-0057-F, audit-ready documentation, and FHIR-native data exchange.
Helios is FHIR-native, so it connects with EHRs, claims systems, partner platforms, and enterprise data sources without disrupting your IT ecosystem. For transactions, E-Connect Clearinghouse handles claims validation, eligibility checks, and remittance processing.
Helios tracks HEDIS® measures, Star Ratings, and care gaps in unified dashboards, and Advanced Analytics flags the members and providers driving performance. Its population health capabilities are NCQA pre-validated, supporting plans pursuing NCQA Population Health Program Accreditation.
Ready to Perform Under Pressure?
Whether you’re preparing for CMS-0057-F API requirements, managing Medicaid redeterminations, or scaling Medicare Advantage, Helios gives your teams one healthcare payer software platform to move with clarity, speed, and measurable impact.