Guide · Triage
Claims triage: send each claim down the right path, with the reason written down.
When claims are triaged by queue, simple claims wait behind complex ones and suspicious ones are paid because nobody looked twice.
Claims triage sorts each new claim into a handling path based on rules: how simple it is, how much is at stake and whether anything looks wrong. A common three-way split is below.
Three paths
| Path | Typical claim | Handling |
|---|---|---|
| Fast track | Covered, small, documents complete, nothing unusual | Minimal touch, quick settlement after approval |
| Standard | Covered but needs assessment or a surveyor | Normal adjuster workflow |
| Investigate | Rules flag something: timing, history, documents, patterns | Investigation queue before any payout |
What triage rules look at
- Cover: is the event within the policy, its limits and waiting periods?
- Value: claim amount against thresholds you set.
- Completeness: are the required documents present and readable?
- Timing: how soon after inception or a policy change did the loss occur?
- History: previous claims on the policy, vehicle or person.
- Consistency: do documents, photos and the story agree?
- Network: is the garage or hospital on your network?
What good triage looks like
- The same rules applied the same way to every claim.
- The reason for each decision recorded with the claim.
- Adjusters able to review and override, with the override logged.
- Payouts approved by people under maker-checker.
- Rules reviewed when investigations find new patterns.
See where triage fits after intake in FNOL on WhatsApp.
How AutoClaims does it
AutoClaims is built for general and health insurers and their TPAs. Customers register a claim on WhatsApp or the portal; photos, bills, discharge summaries and FIRs are read and structured on arrival; cover, waiting periods and limits are checked against the policy. Each claim is triaged by your rules into fast track, standard or investigate, with the reason, and suspicious ones are flagged before payout. Garages, hospitals and surveyors are booked, every step is pushed to the customer, and payouts are approved by people under maker-checker and written through your APIs. Renewals are worked by segment, early, with payment links on WhatsApp. Adjusters and investigators keep every judgement that needs a person.
Questions
What is claims triage?
Sorting each new insurance claim into a handling path, such as fast track, standard or investigate, using rules on cover, value, completeness, timing, history and consistency.
How does triage reduce claims leakage?
Suspicious claims are flagged by rule before payout instead of being found afterwards, and the reason is recorded for investigators.
Should triage decisions be automatic?
Rules can propose the path with the reason, but adjusters should be able to review and override, and payouts should be approved by people.
See it on your own data. AutoClaims — Claims without the status calls. Book a 30-minute working session with an engineer.