INDUSTRY FIELD GUIDE
Insurance claim intake examples for evaluating AI routing
An AI assistant can be tested on whether it sends a claim to the right human queue and identifies missing documents.
NAICS 524126 · Direct Property and Casualty Insurance Carriers
An AI assistant can be tested on whether it sends a claim to the right human queue and identifies missing documents. That is narrower than using it to determine coverage, claim value or eligibility. NAIC’s model bulletin on insurers’ use of AI describes expectations for governance and controls. Scale names financial services and insurance brokerage in its partnership categories. A direct carrier should confirm whether the program accepts its particular records. Confirm whether an actual buyer needs this specific task. NAIC AI model bulletin · Scale Data Partnership
Create a referral test from fictional claims
Build cases with fabricated claimant, incident, policy reference and document status. State which queue the file belongs in, what evidence supports that route, and when uncertainty requires escalation. Include two similar-looking situations with different missing documents and a policy version change that alters the routing rule.
Have trained reviewers score the route and supporting evidence. Keep final disposition and financial outcomes outside this intake benchmark. Use a holdout with a different type of documentation gap so the model must reason from the case rather than repeat a pattern.
Review authority before using real records
Claims can contain medical, financial, location and identity information as well as privileged material. Keep actual policyholder information outside the sample. If a buyer requires operational records, have the appropriate legal, compliance and security teams approve the use, jurisdiction, retention and vendor access.
Start with one fabricated referral and its rubric. Include the decision boundary and the point at which the assistant must hand off to a person. Describe a dataset
Original Fiund exercise
Routing follows the stated missing-document rule and its effective version
Two fabricated intake files use a deliberately simple original queue rubric. It is a documentation benchmark with no real claim, policyholder or insurer workflow.
| Record | Source | What it records |
|---|---|---|
| IR1 | Practice routing rubric | v1 before day 10: missing event form goes to DOCUMENTS. v2 from day 10: missing event form plus an identity-reference conflict goes to REVIEW; missing form alone stays DOCUMENTS. |
| IR2 | File A | Intake day 12, event form missing, identity references consistent. No other disposition record. |
| IR3 | File B | Intake day 12, event form missing, identity alias on cover differs from the attachment. No authoritative resolution supplied. |
Question for the model
Which practice queue follows for each file under the supplied rubric, and what decisions remain outside that routing output?
Show the reference answer and checks
IR1's v2 controls both day-12 files. IR2 has only a missing event form, so A routes to DOCUMENTS. IR3 combines the missing form with an unresolved identity-reference conflict, so B routes to REVIEW. Cite the exact rule and evidence for each referral. These are synthetic human-queue assignments, not determinations of identity, fraud, coverage, claim value, eligibility or entitlement to payment.
- Repeating the older missing-form route after the effective rubric has changed.
- Resolving an identity conflict by assumption instead of following the stated review rule.
Fields to preserve
- Intake date and rubric version
- Selects the applicable practice rule.
- Document gap and conflict evidence
- Supports the route.
- Queue, reason and handoff boundary
- Keeps routing distinct from final disposition.
Test another case
Move B's intake to day 8. Require the v1 route with an explicit conflict note, preserving the distinction between the rubric's output and unresolved evidence.
Use original fictional referrals and reviewer keys. Actual operational use requires separate authorization; exclude medical, financial, identity and privileged claim materials.
Discuss a contribution
Describe the sources you control, the task they could support and what has already been checked. Use the existing-data assessment for an archive or the collection brief for a new recording project. The contributor agreement defines Fiund’s licensing authority and compensation. A guide or fictional exercise does not establish an accepted collection or a sale.