InsureOS: Every Claim, Adjudicated and Paid — at the Speed of Care

A spreadsheet doesn't know a PhilHealth case rate from a co-pay, and it definitely doesn't flag a duplicate claim before the check clears. For a Philippine HMO or third-party administrator, that's not a hypothetical risk — it's the gap between passing an Insurance Commission examination and explaining, after the fact, why a claim got paid twice.

InsureOS is the OS Series' third-party administration platform for Philippine health plans — built by Xamun and delivered by BlastAsia — purpose-built for the administrator stuck between a million-peso international claims suite that's never heard of a PhilHealth case rate and a spreadsheet-and-email process that misses SLA and falls apart at the first regulatory exam.

One Lifecycle, Not a Chain of Disconnected Steps

InsureOS runs the entire claims lifecycle as one system: intake, clinical pre-authorization, adjudication, fraud screening, and disbursement, rather than a set of tools stitched together with email. OCR intake and document audit takes claims arriving from web upload, mobile photo, or partner API and extracts fields with a confidence score, verifies BIR official receipts, and indexes ICD-10 codes — with low-confidence values flagged before they ever reach an adjudicator's desk.

Clinical pre-authorization puts medical, dental, and veterinary LOA requests into one review queue with urgency and aging trackers, backed by pluggable clinical decision support, so reviewers triage the right cases first, on guideline, rather than working through a queue in the order it arrived.

Adjudication Backed by AI, Decided by a Human

AI-assisted adjudication is where InsureOS earns its keep against both a global suite and a spreadsheet: the workbench proposes a settlement — PhilHealth case rate, senior/PWD discount, VAT exemption, co-pay — while an AI assistant scores confidence, validates documents, and checks ICD-10 consistency. The adjudicator still decides. The math is already done, with an explainable rationale attached to every proposed payout, not a black-box number.

Coordination of benefits handles the multi-coverage cases that trip up simpler systems: payer sequencing, PhilHealth-first offsets, and residual member liability calculated automatically, with duplicate and secondary-payer logic built in rather than reconciled by hand after the fact.

Catching the Bad Claim Before the Money Moves

Fraud, waste, and abuse detection scores every flagged claim and ranks it by risk — duplicate claims, excessive frequency, provider outliers — routed to a clear investigation worklist so a team spends its time where the money is actually leaking, before a single peso goes out the door rather than after.

Payout That's BIR-Compliant by Default

Finance, WHT, and reconciliation settles approved claims against a corporate escrow balance with BIR withholding tax calculated per payee, bulk disbursement over PESONet, and carrier-funds reconciliation that produces an audit-ready statement — not a spreadsheet somebody has to reconstruct before an examination.

A Portal Members Actually Use, and Portals for Everyone Else

Member self-service lets members request cashless LOAs against a live benefit balance, file reimbursement claims with their receipts, and track every Explanation of Benefits — with appeals — from an installable web app, no phone calls or paper chase required. Provider and corporate portals give providers a way to submit direct billing and inpatient claims with WHT auto-calculated, HR teams a way to run enrollment and roster management, and carriers a way to watch program performance — each group working in its own workspace instead of routing everything through one overloaded claims team.

Underneath all of it, a workflow rules and SLA engine lets adjudication rules, auto-adjudication thresholds, and escalations get configured without a developer, with turnaround and queue metrics visible on operational dashboards — and RBAC, MFA, and audit reporting across nineteen role-scoped workspaces consolidate logs, overrides, and policy deviations into reports ready for a regulator, not assembled the week before an exam.

Right-Sized for the Administrator in the Middle

InsureOS isn't a scaled-down version of a global claims suite, and it isn't a spreadsheet with better formatting — it's purpose-built for HMOs and health insurers who need PhilHealth-aware adjudication from day one, third-party administrators running multiple corporate and carrier programs at once, corporate health plans handling their own enrollment and member self-service, and clinic and multi-line networks spanning medical, dental, and veterinary billing under one compliant payout process.

Delivered Through BlastAsia's Engagement Models

InsureOS is built by Xamun through the Xamun Software Factory and delivered by BlastAsia through its Turnkey or xDDengagement models, with benefit design and program configuration scoped during onboarding — live in a quarter rather than the multi-year core-claims-system integration a global suite would require, and owned outright as a source-available, perpetually licensed product rather than rented seat by seat.

If your team is still adjudicating claims off a spreadsheet or paying for enterprise capability you don't actually need, let's talk through how InsureOS fits your book of business.