SIU Fraud Referral Decision Worksheet

Documents claim red-flag indicators and the decision to refer a claim to the Special Investigations Unit using written carrier criteria.

Submission Notice

• Purpose of this submission
• I confirm this submission is made for legitimate claims handling and SIU referral purposes only.
• Submission notes
  Add any brief context needed for the audit trail. Avoid unnecessary PII.

Claim Overview

• Claim number
• Date of loss
• Line of business
• Current claim status
• Reported by
• Brief claim summary
  Summarize the claim in 2-4 sentences. Keep the summary factual and avoid speculation.

Red-Flag Indicators

• Red-flag indicators present
• Details of inconsistent statements
  Describe the specific statements that conflict and where the inconsistency was observed.
• Details of suspicious documentation
  Identify the document type and the specific issue, such as altered dates, mismatched signatures, or missing source records.
• Details of prior similar losses
  Include only the minimum necessary facts needed to explain the pattern.
• Other indicator details
  Describe any additional observable red flags not listed above.

Carrier Criteria Review

• Written carrier criteria reference
  Enter the policy, guideline, or procedure name used for the referral decision.
• Does the claim meet written carrier referral criteria?
• Basis for criteria assessment
  Explain which facts support or do not support referral under the written criteria. Keep the explanation factual and concise.
• Is additional internal review needed before referral?
• Reason additional review is needed
  Explain what information is missing or what approval is needed before a final decision can be made.

Referral Decision

• Final referral decision
• Decision rationale
  State the specific reason for the final decision and reference the observable facts and criteria used.
• SIU priority level
• Referral summary for SIU
  Provide a concise summary for SIU intake. Include only the minimum necessary facts.

Audit Trail and Attestation

• Decision maker name
• Decision maker role
• Decision date
• Attestation
  I attest that this worksheet reflects a good-faith review of the claim facts, written carrier criteria, and the minimum necessary information needed for an SIU referral decision.