Governance between insurer and TPA — decision quality, data quality, and full auditability.
A governance layer between the insurer and TPA organizations. It restores transparency and control: what decisions are being made, how complete and consistent the data is, how fast cases move, and where abnormal patterns appear — without replacing your core. It integrates on top of your existing landscape.
Once TPAs are part of the operating model, insurers typically lose standardization and traceability. Data arrives with inconsistent quality, conversations fragment across email, calls, and messengers — and anomalies or leakage are detected too late, after payment decisions. The Control Layer turns TPA management into a controlled, auditable process.
AI guidance on missing items, anomalies, and next best action — grounded in your configured rules and historical patterns.
Abnormal patterns and potential leakage surface before payment decisions and case closure — not after.
Deployed on your infrastructure; LLM capabilities use your own provider keys per your security and compliance policy.
Start with one process and one or two TPAs, measure impact, then scale across lines of business.
Connect to your data sources — claims, policy, provider networks, payments, and other repositories.
The layer assembles full context: coverage, limits, historical behavior, prior decisions.
Rule-based validation plus AI analysis detect abnormal patterns and missing data.
Targeted questions, document requests, and escalation paths are triggered automatically.
Everything is logged and converted into SLA / KPI and audit-ready reporting.
Validate completeness and consistency of every TPA submission against policy context.
Compare performance across TPAs: speed, quality, and consistency of outcomes — not just SLA timers.
A consistent trail of what happened and why — data, actions, and communications linked to each case.
Lower leakage and fewer decision errors, reduced manual workload, faster cycle times, and real visibility into TPA performance — with a complete audit trail.
No — the layer ingests the case flows and updates TPAs already send, validates completeness and logic, and requests missing information automatically. TPAs keep working as they do; you regain visibility and control.
Self-hosted on your infrastructure — data never leaves your perimeter. LLM capabilities use your own provider keys, so you choose the model according to your security and compliance policy.
Every submission is compared against your historical patterns and policy context — rule-based validation plus AI anomaly detection. Outliers (unusual settlement amounts, missing documents, abnormal patterns per provider) surface before payment, not after closure.
A focused pilot: one process, one or two TPAs, agreed metrics. Integration to your data sources is scoped as a separate small project; scale follows measured impact.
One platform. Every line of business. Full cycle, zero paper, evergreen.
Open PINS — Core Insurance Operating SystemTurns incomplete customer emails into structured, insurer-ready claim packages.
Open ClaimMail AIAI agents on top of your existing systems — no core replacement.
Open Agent Layer