Automated insurance support for patients across 1,600 hospitals

Plan coverage and benefits

Questions about plan coverage are consistently the most frequent category in PhilCare's support operation. Members regularly need to confirm what their policy includes – benefit limits, room rates, maternity coverage, dental access, applicable riders, and PhilHealth requirements – and these queries arrive throughout the day, often from people preparing for or already at a clinic visit.

Phil provides members with live benefits information drawn directly from their individual policy records synced via API.

By verifying identity through the chat interface, members can retrieve their full plan details in seconds, without calling the hotline or waiting for an email response.

Plan and benefits enquiries account for the third of all interactions – the highest single category by volume.

Finding accredited hospitals and clinics

For PhilCare members, confirming whether a hospital or clinic is within their network is a necessary step before any consultation or procedure. Previously, this required calling in or waiting for a response, loading agents with highly repetitive lookups.

Phil integrates directly with PhilCare's provider database via API, enabling members to search for accredited hospitals and clinics by name or location in real time. Results reflect live data, ensuring accuracy at any hour.

Accredited healthcare provider queries accounted for 32% of all interactions – making this one of the two dominant use cases by volume.

Claims reimbursement

For treatments covered under reimbursement rather than direct billing, members need to understand the filing process and, in many cases, check the status of a submitted claim.

Phil guides members through the reimbursement process conversationally:

• identifying a patient during the chat,
• confirming coverage eligibility,
• explaining documentation requirements,
• providing status updates for already submited claims.

Structured flows reduce the likelihood of incomplete submissions and help members understand each step before they begin – reducing the downstream volume of follow-up calls driven by rejected or delayed claims.

Billing and payment enquiries

Billing and payment had emerged as one of the highest-volume category, driven by increased enquiries around premium payment failures and billing processes.

Members increasingly use Phil to:

• check payment status,
• understand charges,
• resolve premium concerns before they escalate.

Phil handles these enquiries automatically, providing immediate responses at the point when payment concerns arise – rather than requiring members to wait for a live agent availability or call during office hours. The volume and pace of this category reflect how the platform has evolved: beyond simple lookups, and towards active day-to-day management of members' insurance relationship.

Generating letters of authorisation

A letter of authorisation (LOA) is typically required before a non-emergency consultation or specialist referral – a pre-approval from the HMO confirming coverage for a specific service at a specific provider. Previously, requesting an LOA required contacting the hotline or submitting by email, adding delays to an already time-sensitive step in the patient journey.

Phil automates LOA generation through a direct integration with PhilCare's core systems.

Members can initiate a request within the chat, provide the required details – clinic, doctor, and the visit reasion – and receive their LOA digitally, for both face-to-face and online consultations.

Escalation to live agents – with full context

Phil operates as the first point of contact across PhilCare's digital channels. When a query cannot be resolved automatically – or when a member requests a human – the conversation passes to PhilCare's live support team through Proto's unified Inbox.

When a live agent takes over a chats, they can see the full context:

• full conversation history between the patient and AI agent
• short AI summary of the conversation with patient's sentiment and emotion evaluation
• alll the patients details and personal details - from the current or previous chats
• for repeated patients - full history of previous chats and tickets

AI agent initially handled predictable queries, allowing live agents to focus on cases that genuinely required their involvement. With new workflows built into the AI and new abilities to handle more complex queries around claims and billing, the automation rate has grown year over year, increasing by 50% compared to the previous period.

From deployment to sustained scale

PhilCare has been live on Proto since 2023, making it one of the platform's longest-running healthcare deployments in the Philippines. Monthly interaction volumes have grown from under 10,000 at launch to a range of the 150K+ – a trajectory sustained without proportional growth in the support team.

Peak engagement falls between 8 AM and 10 AM, reflecting members reaching out before and at the start of clinic hours – precisely the window when immediate answers about coverage, provider accreditation, and authorisation matter most. The 24/7 availability of Phil means that queries arriving outside business hours are still resolved instantly, rather than queuing for the next available agent.

PhilCare's sister company, PhilPlans, has followed a parallel path – deploying Proto for pre-need plan enquiries and sales lead generation. As both deployments mature, the group is evaluating a consolidated enterprise structure that would bring PhilCare and PhilPlans under a single AI infrastructure, extending automation further across the group's member and customer-facing operations.