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.
Dernière mise à jour : 16 déc. 2025 - Version v1.0 - Exemple fictif. Ne constitue pas un avis juridique.
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Ce qu'est cet artefact (et quand vous en avez besoin)
Explication minimale viable, écrite pour les audits, pas pour la théorie.
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.
Vous en avez besoin quand
- 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.
À quoi ressemble un bon résultat
Les évaluateurs des critères d'acceptation vérifient réellement.
- 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.
Aperçu du modèle
Un véritable extrait en HTML donc il est indexable et revisible.
## 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)
Comment le remplir (rapide)
Les entrées dont vous avez besoin, le temps de compléter, et un exemple de travail miniature.
Entrées dont vous avez besoin
- 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.
Temps de réalisation : 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)
Comment KLA le génère (Gouvern / Mesure / Prouve)
Attachez l'artefact aux primitifs pour qu'il se convertisse.
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.
FAQ
Écrit pour gagner des réponses de style extrait.
Télécharger l'artefact
Markdown modifiable. Aucun courriel requis.
Download claims triage template