Claims / SIU
A referral, never a determination
Fraud rules at first notice, a points-based review on every claim, cross-book party searches and an AI second opinion — in one place, without ever freezing a legitimate claim.
An adjuster refers with a file note titled “SIU Referral”, which opens a case automatically. SIU cases are worked by admins and managers, and a claim cannot close while a referral is open or investigating.
Does the system decide a claim is fraudulent?
No, and there is no configuration that would let it. Rules and screens raise indicators that score points your organization set. When a claim’s total crosses your supervisor threshold — 5 by default — the claim’s manager gets a task and an email. A determination is the outcome of a person’s investigation.
From signal to outcome
Your rules, your thresholds
01
Fraud Rules At First Notice
Late reporting over 30 days, prior claims, a loss within 14 days of inception or expiration, red-flag terms and possible duplicates — defaults your organization keeps, drops and tunes.
02
Your Question Bank
Groups of questions with points. Yes scores; No and Unknown never score; groups that do not apply to the loss type are greyed.
03
Contact Investigation
Search a name, company, email or phone across the whole book and see every claim it appears on.
04
An AI Second Opinion
An AI screen on one claim or all open claims, where your organization holds SIU screening and has AI switched on. Its score is one more indicator.
05
Closure Is Blocked
A claim cannot close while an SIU referral is open or investigating. The transition refuses rather than warning.
What never holds a claim
Evidence, not accusation
A mis-tuned rule does not just waste time. It creates a documented pattern of accusation against a class of claim, which is a question you may have to answer.
Fraud-rule Hit
An amber strip on the claim — evidence for whoever works it, never an accusation
Industry Fraud Search
Sent only when a person presses the button; a match adds to the score and never holds the claim
Sanctions Screening
Separate: every party screened against the US Treasury lists before money moves
Threshold Crossed
A task and an email to the claim’s manager
Question Bank Changes
Every change audited
Where we are honest
What the platform will not conclude
It routes and records. Every judgment in this area belongs to a person, deliberately.
No Fraud Determination
Not by rule, not by model, not by configuration. A referral is the ceiling of what automation produces here.
Thresholds Are Yours To Defend
We enforce the points and threshold you set. Whether they are reasonable is a question for you, and the record will show what they were.
Investigation Capacity Is Human
Better screening raises more candidates. Without investigators, that is a longer queue rather than a better outcome.
Read next
Bring a referral that went nowhere
And one that found something. We will look at which rules and questions would have scored each, and against what threshold.