Claims Review
Claims review helps teams triage, analyse and document claim files with consistency - supporting adjusters, examiners and referral decisions.
Scenario
A claims team receives a new first notice or full claim file. They need to:
- Understand the facts of loss quickly
- Check coverage and policy conditions
- Identify referral or fraud indicators
- Prepare a structured triage or examination note
Documents and materials required
| Material | Where in Nairo |
|---|---|
| Claim file documents (FNOL, reports, correspondence) | Project upload |
| Policy and endorsement wordings | Project or Library |
| Claims handling guidelines | Library, attached to Claims Expert |
| Triage checklists | Expert rules or Action steps |
Suggested approach
1. Open a Project for the claim
Create a Project and upload the claim file. Organise document types where helpful - FNOL, police report, photos, policy, correspondence.
Monitor processing status and retry failed documents if needed.
2. Extract key facts
Use structured extraction in the Project where configured to pull key fields from the claim file.
Validate and correct extractions manually where the product supports editing.
3. Apply the Claims Expert
Open the built-in Claims Expert with claims handling guidelines as reference materials. Ask:
- “Is this loss potentially covered under the policy wording?”
- “What additional information is needed?”
- “Are there referral triggers based on our guidelines?“
4. Run a structured Action (optional)
If your team uses a claims triage or examination Action, run it with the claim documents as inputs. Review deliverables before use.
5. Human review checkpoint
Before disposition:
- Verify policy references against the actual wording
- Apply coverage judgment where facts or law are ambiguous
- Follow fraud referral protocols independently of AI suggestions
- Record the examiner’s decision in the claims system of record
What this use case is not
This use case does not adjust, pay or deny claims autonomously.
It does not replace the claims management system, legal review or SIU processes.
Coverage determinations require qualified claims professionals.
Related areas
- Projects - document workspace for the claim file
- Experts - claims specialist
- Actions - triage and examination tasks
Getting started
Run a closed claim file your team already adjudicated. Compare Nairo’s triage outputs to the actual outcome and calibrate prompts, Expert rules and extraction fields accordingly.