https://www.insurerbrain.com/w/index.php?action=history&feed=atom&title=Definition%3AClaims_review 2026-06-13T10:46:26Z Revision history for this page on the wiki MediaWiki 1.43.8 https://www.insurerbrain.com/w/index.php?title=Definition:Claims_review&diff=6590&oldid=prev 2026-03-09T16:22:09Z

<p>Bot: Creating new article from JSON</p> <p><b>New page</b></p><div>🔎 &#039;&#039;&#039;Claims review&#039;&#039;&#039; is the structured evaluation of individual [[Definition:Claim | claims]] or a portfolio of claims to verify that handling decisions — [[Definition:Coverage | coverage]] determinations, [[Definition:Reserve | reserves]], valuations, and [[Definition:Claims settlement | settlements]] — are accurate, consistent, and aligned with [[Definition:Policy | policy]] terms and company guidelines. Reviews may be conducted by senior [[Definition:Claims adjuster | adjusters]], dedicated quality-assurance teams, or external [[Definition:Audit | auditors]], and they can target open files, recently closed files, or statistically sampled batches across a [[Definition:Book of business | book of business]].<br /> <br /> 📝 The process typically involves re-examining documentation against a checklist of key controls: Was [[Definition:Coverage | coverage]] correctly confirmed? Are reserves set at appropriate levels given current evidence? Were required investigations completed? Did the adjuster follow [[Definition:Litigation management | litigation management]] protocols where applicable? Findings are scored or categorized, and patterns — such as chronic under-reserving in a particular [[Definition:Class of business | class of business]] or repeated procedural lapses by a specific team — are escalated to management for corrective action. Many [[Definition:Insurance carrier | carriers]] embed automated triggers in their [[Definition:Claims management system | claims management systems]] to flag files that meet review criteria, blending technology with human judgment.<br /> <br /> ✅ Regular claims reviews are one of the most direct levers for controlling [[Definition:Claims leakage | claims leakage]] and maintaining [[Definition:Reserve adequacy | reserve adequacy]]. They also serve a compliance function: regulators and [[Definition:Reinsurer | reinsurers]] frequently require evidence that an insurer&#039;s [[Definition:Claims management | claims-handling]] practices are subject to systematic oversight. Beyond the numbers, a strong review culture sharpens adjuster skills through feedback loops and reinforces the standards that protect both the company&#039;s financial position and the [[Definition:Policyholder | policyholder&#039;s]] right to fair treatment.<br /> <br /> &#039;&#039;&#039;Related concepts&#039;&#039;&#039;<br /> {{Div col|colwidth=20em}}<br /> * [[Definition:Claims management]]<br /> * [[Definition:Claims leakage]]<br /> * [[Definition:Reserve adequacy]]<br /> * [[Definition:Claims adjuster]]<br /> * [[Definition:Audit]]<br /> * [[Definition:Quality assurance]]<br /> {{Div col end}}</div>

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