Claims Triage

What is Claims Triage?

Claims triage is the critical process of evaluating incoming claims and routing them to the appropriate resources for handling. Just as hospital emergency rooms triage patients by severity to ensure the most critical cases get immediate attention, insurance claims triage sorts claims by severity, complexity, and required expertise to ensure each claim reaches the right adjuster with the right skills at the right time.

The triage decision determines the entire trajectory of the claim. Route a complex liability claim with serious injury to a junior adjuster with property expertise, and you guarantee poor outcomes - inadequate investigation, missed coverage issues, settlement mistakes, and likely litigation. Route a simple auto glass claim to a senior adjuster with medical expertise, and you waste expensive resources on routine work. Route a potentially fraudulent claim to normal handling, and you miss the fraud indicators that should trigger special investigation.

Effective triage is fundamental to claims operations efficiency, quality outcomes, and appropriate resource utilization. It's also an area where traditional manual processes create significant delays and inconsistent decisions - making it a prime target for automation.

How Claims Are Prioritized and Routed

Claims triage evaluates multiple dimensions to determine appropriate routing:

Severity: The seriousness of loss drives immediate prioritization. Severity assessment considers: injury severity (fatality, serious injury, minor injury, property damage only), loss amount (catastrophic losses over $500K, large losses $100-500K, medium losses $10-100K, small losses under $10K), potential exposure (considering liability, policy limits, and worst-case scenarios), and immediate action needs (hospitalized claimant requiring immediate contact, emergency property repairs, total loss vehicle needing immediate settlement).

Catastrophic severity claims route immediately to senior adjusters or specialized catastrophic claim units. They require immediate attention, sophisticated handling, and often special authorities. Simple, low-severity claims can route to junior adjusters, automated workflows, or even straight-through processing.

Complexity: Claim complexity, independent of severity, determines required expertise. Complexity factors include: number of parties involved (single-vehicle vs multi-vehicle accident, solo slip-and-fall vs multi-party premises liability), legal or coverage complexity (disputed liability, novel coverage questions, policy interpretation issues), investigation requirements (extensive medical review, engineering analysis, surveillance needs), multi-state or international dimensions, and regulatory complications (claims involving public entities, regulated industries, or special reporting requirements).

Complex claims route to experienced adjusters with proven ability to handle sophisticated investigations and negotiations, even if the current severity is moderate. Simple claims route to junior staff or automated processes.

Specialization Requirements: Certain claims require specific expertise. Medical expertise for health claims, workers' comp, and serious injury liability claims, legal expertise for litigated claims or those likely to litigate, property expertise for building damage assessment and repair oversight, auto expertise for vehicle damage evaluation and diminished value assessment, fraud investigation expertise for claims with fraud indicators, and industry-specific knowledge for specialized commercial lines (aviation, marine, professional liability).

The triage process matches claim characteristics to adjuster specializations, ensuring claims reach staff with relevant expertise.

Manual vs Automated Triage

Traditional manual triage and modern automated triage differ dramatically in speed, consistency, and outcomes:

Manual Triage Process: In traditional operations, incoming claims land in a general queue or inbox. A triage supervisor or senior adjuster periodically reviews the queue (often several times daily, sometimes only once daily), reads each claim summary or FNOL, mentally evaluates severity and complexity based on experience and judgment, considers which adjusters have capacity and appropriate skills, and manually assigns each claim to an adjuster or team.

This process has significant weaknesses. Delays are inevitable - claims sit in queue until the next triage session, which might be hours or a full business day. Inconsistency is common - different supervisors apply different judgment; assignment decisions vary based on who's doing triage. Workload imbalances develop - some adjusters get overloaded while others have capacity. Visibility is limited - there's no systematic tracking of triage patterns, assignment rationale, or routing decision quality.

Automated Triage Process: Modern automated systems triage claims instantly upon FNOL receipt. The system analyzes claim data and narratives using business rules and AI, scoring severity based on injury indicators, loss amount, liability complexity, and other factors. It determines appropriate workflow (straight-through processing, standard handling, complex investigation, fraud review). It identifies required expertise from loss type and characteristics. It routes to the appropriate adjuster considering skills, workload, geographic territory, language capabilities, and any special handling requirements.

Assignment happens in seconds rather than hours. Every claim gets evaluated using consistent logic. Workload is balanced automatically. And the entire process is tracked and auditable, enabling continuous improvement of routing rules.

Criteria for Routing Decisions

Sophisticated triage systems consider multiple factors in routing decisions:

Loss Amount Thresholds: Many operations define routing based on reserve or actual loss amount ranges. Claims under $5,000 might route to junior adjusters or automated processing. Claims $5,000-50,000 route to standard adjusters. Claims $50,000-250,000 route to senior adjusters. Claims over $250,000 route to specialized large-loss units. These thresholds are configurable and vary by line of business and carrier.

Injury Severity: Presence and severity of injury is a critical routing factor. Property damage only claims route to one workflow. Minor injury (medical treatment only) routes to another. Serious injury (hospitalization, permanent impairment) routes to specialized injury adjusters. Fatality claims route to the most experienced adjusters with special training in death claim handling and sensitivity.

Line of Business: Claims route to adjusters specialized in the relevant line. Auto physical damage to auto specialists. Workers' compensation to workers' comp units. General liability to liability adjusters. Commercial property to commercial property teams. This specialization improves handling quality and efficiency.

Geographic Location: Many carriers route by territory. An auto claim in California routes to California adjusters who understand California law, know local repair networks, and can easily conduct field investigations. Multi-state operations benefit from geographic routing to maintain local expertise and relationships.

Language Requirements: Claims involving claimants who speak languages other than English should route to bilingual adjusters or teams with interpreter access. Automated systems can detect language needs from claimant communications and route accordingly.

Fraud Indicators: Claims flagged for potential fraud route to special investigation units (SIU) or fraud-trained adjusters. Fraud indicators include recent policy inception, inconsistent information, prior fraud history, suspicious loss patterns, or known fraud locations/providers. Automated fraud scoring can identify these indicators instantly and route appropriately.

Customer Tier: Some carriers route high-value customers (large commercial accounts, VIP personal lines customers, major agents' clients) to specialized teams providing enhanced service. The triage system recognizes customer tier from policy data and routes accordingly.

Benefits of Automated Triage

Automating claims triage delivers multiple operational and customer experience benefits:

Consistent Decisions: Every claim is evaluated using the same logic and criteria. There's no variation based on who performs triage or how busy they are. This consistency improves quality and eliminates assignment arbitrariness.

Faster Assignment: Claims route to adjusters within seconds of FNOL rather than sitting in queues for hours or days. This speed enables faster first contact, better SLA compliance, and improved customer experience.

Optimized Workload Distribution: Automated routing considers current adjuster workload, ensuring claims distribute evenly. Adjusters with capacity receive new assignments while those already at full workload don't get additional claims until they close some. This prevents burnout, maintains quality, and optimizes staff utilization.

Expertise Matching: Complex claims consistently reach experienced adjusters. Specialized claims reach specialists. This matching improves outcomes, reduces errors, and ensures appropriate resource allocation.

Auditability and Improvement: Automated systems track all routing decisions, creating data for analysis. Managers can review: what percentage of claims route to each workflow, whether severity scoring accurately predicts actual claim outcomes, if workload balancing is effective, and where routing rules need adjustment. This visibility enables continuous improvement impossible with manual processes.

Scalability: Manual triage doesn't scale - as claim volume increases, you need more triage supervisors and the process slows down. Automated triage handles 1,000 claims or 100,000 claims with the same speed and consistency.

AI-Powered Severity Scoring

Modern triage systems use AI to assess severity from unstructured loss narratives:

Natural language processing analyzes FNOL narratives to identify severity indicators. The AI detects injury keywords ("ambulance," "hospital," "fracture," "unconscious") that signal serious injury. It identifies high-severity property damage indicators ("total loss," "fire," "collapse," "destroyed"). It recognizes liability complexity signals ("multiple vehicles," "commercial property," "child injured," "public entity"). It scores fraud risk from linguistic patterns and inconsistencies.

These AI severity scores feed into routing logic. A claim with high injury severity score automatically routes to injury specialists. A claim with high fraud score routes to SIU. A claim with low severity and complexity scores routes to junior adjusters or STP workflows.

The AI continuously learns from outcomes. When claims initially scored as low-severity develop into large losses, the system learns to recognize similar patterns earlier. This continuous improvement makes routing progressively more accurate over time.

Claims triage automation is foundational to modern claims operations. The carriers who implement intelligent automated triage achieve faster processing, better outcomes, optimal resource utilization, and superior customer experience - all while reducing operational costs and improving adjuster satisfaction through better workload management.