A modern third-party administration platform for Philippine HMOs and health insurers — cashless LOA, AI-assisted claims adjudication, clinical pre-authorisation, coordination of benefits, fraud detection and BIR-compliant disbursement. PhilHealth, BIR and Data Privacy Act compliance are built in, across medical, dental and veterinary lines.
A modern third-party administration platform for Philippine HMOs and health insurers — cashless LOA, AI-assisted claims adjudication, clinical pre-authorisation, coordination of benefits, fraud detection and BIR-compliant disbursement. PhilHealth, BIR and Data Privacy Act compliance are built in, across medical, dental and veterinary lines.
InsureOS is built for tpa teams in insurance. It is delivered under Outcome-as-a-Service: Xamun invests the build, deploys it on your infrastructure, and you pay per transaction the system processes.
InsureOS carries the following regulatory and compliance surface, enforced in the workflow rather than documented beside it. The GraphIQ compliance layer keeps these rules current as they change.
Not a generic CRM with a claims bolt-on. Every module is shaped around how regulated health administration works here.
AI-assisted adjudication The workbench proposes a settlement — PhilHealth case rate, senior/PWD discount, VAT exemption and co-pay — while an AI assistant scores confidence, validates documents and checks ICD-10 consistency. The adjudicator decides; the math is done.
OCR intake & document audit Claims arrive from web, mobile photo or partner API. OCR extracts fields with a confidence score, verifies BIR official receipts and indexes ICD-10 — low-confidence values flagged before adjudication.
Clinical pre-authorization Medical, dental and veterinary LOA requests in one queue with urgency and aging trackers — plus pluggable clinical decision support, so reviewers approve the right cases first, on guideline.
Coordination of benefits Determine payer sequencing, apply PhilHealth-first offsets and calculate residual member liability for multi-coverage claims — duplicate and secondary-payer logic built in.
Fraud, waste & abuse detection Every finding is scored — duplicate claims, excessive frequency, provider outliers — and routed for investigation before a single peso goes out the door.
Finance, WHT & reconciliation Settle approved claims against the corporate escrow balance with BIR withholding tax per payee, bulk disbursement over PESONet, and carrier-funds reconciliation — every statement audit-ready.
Member self-service Members request cashless LOAs, file reimbursement claims with their receipts, and track every Explanation of Benefits — with appeals — from an installable web app, no app store needed.
Provider & corporate portals Providers submit direct billing, GOP and inpatient claims with WHT auto-calculated; corporate HR runs enrollment and roster; carriers watch program performance — each in its own workspace.
Workflow rules & SLA engine Configure adjudication rules, auto-adjudication thresholds, escalations and SLA clocks without a developer — and watch turnaround and queue metrics in operational dashboards.
RBAC, MFA & audit reporting Nineteen role-scoped workspaces, MFA enforcement and an access-control console — consolidating logs, overrides, exceptions and policy deviations into regulator-ready compliance reports.
Real screens from the live demo you can open above. Your own deployment is a separate instance, branded and configured to your operation.
Stacked against the ways Philippine HMOs and TPAs run their claims today.
| Capability | InsureOS Purpose-built for PH | Global claims suite(international vendors) | Generic health SaaS(foreign platforms) | Spreadsheets / email |
|---|---|---|---|---|
| PhilHealth case-rate adjudication | ● Built-in | ✕ Custom build | ✕ Not localized | ✕ Manual |
| AI-assisted settlement & confidence scoring | ● Native | ◑ Add-on | ◑ Varies | ✕ None |
| BIR withholding tax & official-receipt audit | ● Built-in | ✕ Not localized | ✕ No | ◑ Manual |
| Clinical pre-auth: medical, dental & veterinary | ● One queue | ◑ Medical only | ◑ Varies | ✕ None |
| OCR intake & ICD-10 indexing | ● Built-in | ◑ Module | ◑ Generic | ✕ Manual |
| Fraud, waste & abuse detection | ● Risk-scored | ◑ Add-on | ◑ Varies | ✕ None |
| Coordination of benefits (PhilHealth-first) | ● Built-in | ◑ Configurable | ✕ Not localized | ✕ Manual |
| PESONet bulk disbursement & reconciliation | ● Native | ◑ Integration project | ◑ Custom | ✕ Manual |
| Member & provider self-service portals | ● Included | ✕ Separate project | ◑ Varies | ✕ None |
| SLA engine & audit-ready compliance reports | ● Built-in | ● Yes | ◑ Varies | ✕ Error-prone |
| Time to go live | ● Weeks | ✕ 12–24 months | ◑ Months | ● Immediate* |
| Source code ownership & white-label | ● You own & rebrand it | ✕ Vendor-locked | ✕ Vendor's product | ◑ Files only |
| Hosting & data residency control | ● Your infra, any region | ◑ Vendor-defined | ✕ Vendor cloud only | ◑ Your device |
| Commercial model | ● One-time perpetual licence | ✕ Licence + integrator | ✕ Recurring per-seat SaaS | ◑ Cheap, then costly |
Under Outcome-as-a-Service, with no upfront CAPEX. What you open above is a demo instance; what you buy is your own separate deployment — on your infrastructure, under your brand, source-available, and configured to how your operation actually works. Xamun invests the build, and you pay a per-transaction fee on what the system processes. A slow month is a small invoice; if it does not run, you do not pay.
Bring us one workflow and we will show you InsureOS running it.
