Field Guide to Gnarly Claims

Clear, opinionated answers to the terms shaping claims and insurance.

Definitions

Plain-language answers to the claims and insurance terms we work with every day.

A

  • Adjuster copilot

    An adjuster copilot is AI that works alongside claims adjusters on open files. It reads the claim file, flags risks and deadlines, and recommends next steps with its reasoning. The adjuster keeps authority over every decision.

  • AI claims audit

    An AI claims audit uses AI to review claim files for handling quality, including coverage and liability decisions, reserving, timeliness, and recovery. It can review every file in a book, where a manual audit samples about 2%, and human auditors check its findings.

C

  • Claims audit software

    Claims audit software helps carriers, MGAs, TPAs, and self-insured organizations review claim files for handling quality and compliance. It manages audit criteria, records findings, and reports results; AI-based tools also read the files and draft the findings.

  • Claims leakage

    Claims leakage is money lost on covered claims through handling failures: the gap between what an insurer pays, including loss adjustment expense (LAE), and what it would have paid if each claim had been handled to its own guidelines.

  • Claims quality review

    A claims quality review, also called claims QA or claims quality assurance, is an internal check of claim files against best practices and the organization's own handling guidelines. Reviewers score each file on coverage, contact, investigation, reserving, documentation, payment, and closure.

P

  • P&C TPA (third-party claims administrator)

    A P&C TPA, or third-party claims administrator, handles property and casualty claims for a carrier, MGA, or self-insured organization, from first notice of loss to resolution, under the client's guidelines and authority.

T

  • TPA audit

    A TPA audit reviews how a third-party administrator handles claims for a carrier, MGA, or self-insured organization. It checks claim files against the client's guidelines, authority levels, and best practices, and it supplies the evidence for TPA oversight.