Annex IV template: Insurance claims triage
Download an Annex IV technical documentation template tailored to insurance claims triage: routing, fraud flags, oversight, monitoring, and evidence prompts.
Draft a claims triage Annex IV doc you can review in ~60 minutes.
For compliance, risk, product, and ML ops teams shipping agentic workflows into regulated environments.
Zuletzt aktualisiert: 16. Dez. 2025 · Version v1.0 · Fiktives Beispiel. Keine Rechtsberatung.
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Was dieses Artefakt ist (und wann Sie es brauchen)
Minimal funktionsfähige Erklärung, geschrieben für Audits, nicht für Theorie.
A system-type Annex IV template for insurance claims triage: triage/routing, fraud suspicion, severity scoring, and the evidence you need to defend decisions.
It emphasizes reviewer UX and traceability: what humans see, what they can do, and what is recorded automatically.
Sie brauchen dies, wenn
- Your system routes or prioritizes claims, flags suspicious activity, or influences payout decisions.
- You need to defend triage and fraud flagging accuracy with exportable evidence.
- You are operationalizing monitoring, escalation, and incident response for production use.
Common failure mode
A documentation pack that ignores reviewer workflows (what they see, what buttons exist) and cannot reproduce decisions across versions and evidence.
Erfolgskriterien
Akzeptanzkriterien, die Prüfer tatsächlich überprüfen.
- Claim types, routing outcomes, and advisory vs automatic behavior are explicit.
- Data handling covers attachments and sensitive content (redaction and access control).
- Human oversight covers high payout, vulnerable customer, or safety-related triggers.
- Monitoring includes false positive/negative costs and customer impact metrics (delays, complaint rate).
- Exports tie claim decisions to trace IDs, policy versions, and reviewer actions.
Vorlagenvorschau
Ein echter Auszug in HTML, damit er indexierbar und prüfbar ist.
## 3) Monitoring, functioning, control - Known failure modes (document quality, language, edge-case claim types) - Human oversight triggers (high payout, safety issues, vulnerable customers) ## 4) Performance metrics - Triage accuracy/precision/recall (by claim type) - False positives vs false negatives (cost model)
Wie man es (schnell) ausfüllt
Benötigte Eingaben, Zeit zum Abschließen und ein minimales Arbeitsbeispiel.
Benötigte Eingaben
- Claim triage workflow description and tool permissions.
- Data sources (forms, notes, attachments) and redaction rules.
- Metrics + thresholds (accuracy by claim type, customer impact).
- Oversight SOP + monitoring plan references.
Zeit zum Abschließen: 45–90 minutes for v1.
Mini example: always-review trigger
Always-review: - Any claim flagged “potential fraud” with confidence > 0.8 - Any claim with projected payout > €10k - Any claim containing safety-critical elements (injury, property hazard)
Wie KLA dies generiert (Govern / Measure / Prove)
Verknüpfen Sie das Artefakt mit Produktfunktionen.
Govern
- Policy-as-code checkpoints that block or require review for high-risk actions.
- Versioned change control for model/prompt/policy/workflow updates.
Measure
- Risk-tiered sampling reviews (baseline + burst during incidents or after changes).
- Near-miss tracking (blocked / nearly blocked steps) as a measurable control signal.
Prove
- Hash-chained, append-only audit ledger with 7+ year retention language where required.
- Evidence Room export bundles (manifest + checksums) so auditors can verify independently.
Häufige Fragen
Prägnante Antworten auf häufige Fragen.
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Download claims triage template