Insurance Claims Triage Playbook v1.0

Install

Start with the ZIP package, then choose the AI tool workflow that fits your setup.

1. Download insurance-claims-triage-playbook.zip (6.7 KB).
2. Open the package and read SKILL.md, plus any included references, templates, or scripts.
3. Use the instructions directly in any AI tool that supports reusable instructions, project knowledge, custom agents, or uploaded reference files.

For Claude Code, unzip into ~/.claude/skills/ so the folder lands at ~/.claude/skills/insurance-claims-triage-playbook/, then reload Claude Code. For Claude.ai, upload the same ZIP from Customize → Skills.

Use with other AI tools

This package is not locked to one vendor. If your AI tool does not support Claude-style skills, copy the core instructions from SKILL.md into the tool's custom instructions, project prompt, agent setup, or reusable prompt library.

• Upload or paste any included reference files as project knowledge where your tool supports it.
• Keep the output format from SKILL.md intact so results stay predictable.
• Run a small test with your own data before using the workflow in production.

Compatibility depends on the features your AI tool provides. Treat scripts as optional local helpers unless your environment can run them safely.

Claude installation reference

The Problem

Claims adjusters receive dozens of new claims each day—auto accidents, property damage, liability cases. Not all claims are equal. Some carry immediate legal exposure, others hide suspicious patterns, and a few land in a gray area where coverage is unclear. Manually sorting through each one eats hours that could be spent on high-risk files. Most triage happens in someone’s head, without a consistent framework. That’s where this skill comes in.

Quick Scan

• Best for: Property & casualty adjusters, team leads, claims operations
• Output: A ranked triage report with urgency score, coverage assessment, fraud flags, and recommended next action
• Inputs: Claim details (date of loss, type, description, involved parties, policy limits, known damages)
• Time saved: 10–15 minutes of manual analysis per claim, often more on complex files
• Main caveat: The skill flags issues for human review; it does not decide coverage or liability

What It Does

The Insurance Claims Triage Playbook turns a raw claim submission into a structured triage report. It walks Claude through three lenses—severity, coverage, and fraud indicators—then assigns a priority tier and an actionable next step.

You feed in the key facts of a claim, and the skill:

1. Extracts all red-flag details that signal high severity (bodily injury, large property damage, potential litigation).
2. Checks the policy for coverage gaps—exclusions, deductibles, sub-limits—and flags ambiguous language.
3. Evaluates for common fraud indicators (late reporting, inconsistencies, prior claims history).
4. Produces a single-page triage scorecard with a recommended action: immediate review, standard processing, or low-priority queuing.

The output is not a substitute for an adjuster’s judgment—it’s a repeatable, auditable first pass that brings the most urgent claims to the top of your desk every morning.

When to Use It

• You have a morning stack of new claims and need to decide which three to look at first.
• A complex claim lands with multiple parties and possible coverage issues—you want a systematic breakdown before diving in.
• Your team wants a consistent triage method that can be documented for internal audits.

When Not to Use It

• Claims that are already under litigation or have an attorney involved—direct attorney review is required.
• Highly specialized lines (marine, aviation, surety bonds) where domain-specific regulations dominate. The skill’s generic checks may miss line‑specific nuances.
• Simple, low-value claims that follow a fixed settlement matrix (e.g., minor auto dings under $1,500). The overhead of the skill may not be justified.

How to Install and Use

1. Download the ZIP and copy the claims-triage-playbook folder into your AI workflow skills directory, or upload the folder via Claude’s skill upload interface.
2. In a Claude session, type: Triage this claim and paste the claim details.
3. Claude will ask for any missing required inputs (date of loss, policy type, etc.) and then walk through the analysis.

A Concrete Example

Input

Claim ID: CL-2025-0421

Policy: Commercial General Liability, $2M per occurrence

Date of loss: April 10, 2025

Type: Slip-and-fall at insured’s retail store

Description: Customer claims to have slipped on a wet floor near the entrance after a rainy day. Reports back and knee pain, has retained an attorney. No video footage available. Store manager says warning sign was placed, but no witness can confirm.

Damages: Medical bills so far $8,200; lost wages claimed at $15,000; pain and suffering demand of $30,000.

Claim history: Insured has had two previous liability claims in the past 18 months.

Output (excerpt)

## Claims Triage Report — CL-2025-0421

**Severity Score:** 5/5 — Attorney involvement, bodily injury, potential litigation, lost wages claim
**Coverage Assessment:** Policy responds; sub‑limit for medical payments is $10K (excess over bodily injury limits). No clear exclusion triggered, but warning‑sign placement may affect negligence determination.
**Fraud Indicators:** 2 red flags — attorney retained within 48 hours; insured’s claim frequency (3 claims in 18 months) exceeds industry average
**Recommended Action:** Immediate review — assign to senior adjuster; request incident report and maintenance logs; open reserve at $50,000

Limitations

1. Not a coverage opinion: The skill highlights potential coverage gaps, but final coverage determination must be made by a licensed adjuster or counsel, especially when policy language is ambiguous.
2. Fraud detection is suggestive only: The fraud indicators are based on common red flags (NICB patterns, industry benchmarks). The skill cannot detect sophisticated staged accidents or professional fraud rings; it just raises flags for human investigation.
3. Jurisdiction‑specific requirements: The skill does not incorporate state‑specific regulations (e.g., California’s Fair Claims Settlement Practices). If you operate in a highly regulated market, you’ll need to overlay those rules manually after the triage.

Download the Skill

Get the full playbook as a ZIP — includes SKILL.md, README, license, and metadata. Just drop it into your AI skills and start triaging claims in minutes.

Related Skills

• Boutique Hotel Guest Recovery Mapper — if you handle property claims in hospitality, mapping recovery workflows after an incident fits hand‑in‑glove with a triage system.
• SaaS Churn Risk Briefing Studio — although in a different sector, the structured risk‑scoring approach translates well to insurance renewal triage workflows.

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