InsureOS — Every claim, adjudicated and paid.
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.
What is InsureOS?
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.
Who is InsureOS for?
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.
What regulation does InsureOS handle?
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.
- VAT
- BIR
What can InsureOS do?
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.
What does InsureOS look like?
Real screens from the live demo you can open above. Your own deployment is a separate instance, branded and configured to your operation.
The winning balance of cost and capability
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 |
How do you buy InsureOS?
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.
Where InsureOS fits
See InsureOS on your own numbers
Bring us one workflow and we will show you InsureOS running it.