In P&C insurance, a QA claim is a claim file selected for quality assurance review. A reviewer scores how the file was handled, from coverage and contact to reserving, payment, and closure, against best practices and the organization's guidelines. In health insurance, claims QA usually means checking processing and payment accuracy, such as coding and pricing.

Is claims QA the same as a claims audit?

They overlap. Claims QA, or quality review, is usually an ongoing internal check, often on open files, so problems get fixed before the claim resolves. A claims audit is usually periodic, often run by an outside party such as a carrier reviewing its TPA, and mostly looks at closed files. Both score files against best practices and guidelines.

Who performs claims quality reviews?

Usually a quality or technical team inside the claims organization, or claims supervisors reviewing their own adjusters' files. TPAs run quality review on the files they handle for clients, and MGAs use it to show capacity providers how delegated claims are handled. Some teams add software that reads each file and drafts findings for reviewers to check.

Field Guide definitionSeptember 29, 2026

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.

What is a claims quality review?

A claims quality review is a structured read of a claim file against a checklist of handling standards. Carriers, TPAs (third-party administrators), and MGAs (managing general agents) with delegated claims authority run them internally. Claims teams rarely call this work an audit; they call it quality review, QA, or file review.

The standards come from two places: best practices for the line of business, and the organization's own claim handling guidelines. For a TPA, those guidelines include each client's service instructions and authority levels.

What does a claims quality review check?

Was coverage confirmed, or reserved in writing when the facts called for a reservation of rights (a notice that the insurer may still dispute coverage)?
Were the insured, the claimant, and other parties contacted within the time the guidelines set?
Did the investigation gather the statements, documents, and expert input that the liability and damages questions needed?
Was the first reserve set on time, and was it updated when the exposure changed?
Do the notes explain each decision, and does the file have a current plan of action?
Were payments accurate, within authority, and made to the right parties?
Was subrogation (recovering the payment from a responsible third party) considered, and was the file closed promptly after the final payment?

How is a quality review different from a claims audit?

The checklists look alike. The difference is timing and who runs the review. Quality review is ongoing and internal: the claims organization reviews its own files, often while they are open, so a supervisor can correct a missed step before the claim resolves.

A formal claims audit is usually periodic and often run by an outside party, such as a carrier reviewing its TPA, a capacity provider reviewing an MGA, or a reinsurer reviewing ceded claims. Audits mostly look at closed files to judge performance over a period; see AI claims audit and TPA audit.

How are files selected for review?

Most teams review a sample. Some pick a set number of files per adjuster each period; others target files by risk, such as large losses, litigated claims, or files near an authority limit. Sampling keeps the reviewers' workload manageable.

The limit is coverage. A sample shows how a small share of files were handled, so a pattern that runs across hundreds of files can go unseen, and a closed-file sample finds problems after the money is paid. Estimates of claims leakage from a sample are extrapolations. Some teams now use claims audit software to review a larger share of files, including open ones.

What does a quality review produce?

Each file gets a score against the checklist and a list of findings. A useful finding names the note, document, or payment it rests on, so the adjuster can see exactly what was missed. File scores roll up by adjuster, team, office, or TPA.

The results feed coaching for individual adjusters, corrections on files that are still open, and changes to training or guidelines when the same miss appears across a team. Findings with a dollar effect, such as an unpursued recovery, also feed the leakage estimate.

Ely Audit is Elysian's AI claims audit and QA software. It reviews open and closed files against best practices and a team's own guidelines, and cites a source in the claim file for every finding.

FAQ

What is a QA claim?
In P&C insurance, a QA claim is a claim file selected for quality assurance review. A reviewer scores how the file was handled, from coverage and contact to reserving, payment, and closure, against best practices and the organization's guidelines. In health insurance, claims QA usually means checking processing and payment accuracy, such as coding and pricing.
Is claims QA the same as a claims audit?
They overlap. Claims QA, or quality review, is usually an ongoing internal check, often on open files, so problems get fixed before the claim resolves. A claims audit is usually periodic, often run by an outside party such as a carrier reviewing its TPA, and mostly looks at closed files. Both score files against best practices and guidelines.
Who performs claims quality reviews?
Usually a quality or technical team inside the claims organization, or claims supervisors reviewing their own adjusters' files. TPAs run quality review on the files they handle for clients, and MGAs use it to show capacity providers how delegated claims are handled. Some teams add software that reads each file and drafts findings for reviewers to check.

Related definitions

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.
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 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.

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