SIU Fraud Referral Decision Worksheet
This SIU Fraud Referral Decision Worksheet captures claim red flags, carrier criteria, and the final decision to refer or not refer a claim to Special Investigations. It gives adjusters a consistent record for defensible, auditable referrals.
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Overview
The SIU Fraud Referral Decision Worksheet is a workplace form for documenting suspected fraud indicators and the decision to refer a claim to the Special Investigations Unit. It organizes the claim overview, the specific red flags observed, the carrier criteria reviewed, and the final referral decision in one place so the file shows how the conclusion was reached.
Use this template when a claim presents facts that may warrant escalation, when a supervisor wants a documented second look, or when you need to record why a claim was not referred despite concerns. The form is especially useful for claims teams that need a repeatable process across adjusters, lines of business, or offices. It also helps create an audit trail for internal review, compliance checks, and later file reconstruction.
Do not use this worksheet as a substitute for the carrier's SIU policy, legal advice, or a full investigation report. It is not meant for every routine claim, and it should not be used to collect unnecessary personal data. Keep the content focused on facts already relevant to the claim, use only the fields needed for the decision, and apply progressive disclosure if your workflow adds extra review steps. If a claim does not present any meaningful indicators, a lighter claim note may be enough instead of a full referral worksheet.
Standards & compliance context
- Limit the worksheet to claim facts needed for the referral decision to support GDPR Article 5 data minimization and reduce unnecessary PII collection.
- If the form is used in a public-facing or employee-accessible workflow, make labels, validation, and navigation accessible under WCAG 2.1 AA.
- Use an attestation field and audit trail to preserve accountability for the referral decision and support internal review requirements.
- Avoid collecting sensitive personal details unless they are necessary to the claim decision and permitted by your carrier policy or applicable law.
General regulatory context for orientation only — verify current requirements with counsel or the relevant agency before relying on this template for compliance.
What's inside this template
Submission Notice
This section sets expectations for why the worksheet is being completed and what the submitter is acknowledging before any claim details are entered.
- Purpose of this submission
- I confirm this submission is made for legitimate claims handling and SIU referral purposes only.
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Submission notes
Add any brief context needed for the audit trail. Avoid unnecessary PII.
Claim Overview
This section captures the minimum claim context needed to understand the referral decision without over-collecting unrelated information.
- Claim number
- Date of loss
- Line of business
- Current claim status
- Reported by
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Brief claim summary
Summarize the claim in 2-4 sentences. Keep the summary factual and avoid speculation.
Red-Flag Indicators
This section records the specific facts that raised concern so the referral decision is tied to observable indicators rather than a general suspicion.
- 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
This section shows which written criteria were checked and whether the claim actually meets the threshold for SIU escalation.
-
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
This section documents the final outcome, the reasoning behind it, and the priority level for the SIU handoff if a referral is made.
- 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
This section preserves accountability by identifying who made the decision, when it was made, and that the reviewer stands behind the record.
- Decision maker name
- Decision maker role
- Decision date
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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.
How to use this template
- 1. Enter the claim basics, including claim number, loss date, line of business, claim status, reported by, and a short factual summary of the loss.
- 2. Record the specific red-flag indicators you observed and add brief details for any inconsistent statements, documentation concerns, prior loss history, or other relevant concerns.
- 3. Reference the carrier's SIU criteria, mark whether the criteria are met, and explain the factual basis for that determination in plain language.
- 4. State whether additional review is needed, identify why a second look is required if applicable, and note any missing facts that affect the decision.
- 5. Document the referral decision, summarize the rationale, assign SIU priority if your process uses one, and write a concise referral summary for the file.
- 6. Complete the audit trail by entering the decision maker's name, role, date, and attestation before saving or submitting the worksheet.
Best practices
- Use objective claim facts, not conclusions, in the red-flag fields so the worksheet shows what was observed rather than speculation.
- Reference the exact carrier criterion or internal rule you applied instead of writing a vague statement like 'suspicious claim.'
- Keep the brief claim summary short and relevant to the referral decision so the form follows data minimization and avoids unnecessary PII.
- Use conditional logic to show additional review fields only when the reviewer marks the claim as borderline or incomplete.
- Capture the decision on the same day the review is completed so the audit trail reflects the contemporaneous reasoning.
- Write the referral summary as a neutral handoff note that another reviewer can understand without reading the entire file.
- If the claim is not referred, document the reason clearly so the file shows why escalation was declined.
What this template typically catches
Issues teams running this template most often surface in practice:
Common use cases
Frequently asked questions
What is this worksheet used for?
Use it to document why a claim was escalated to the Special Investigations Unit, or why it was not. The template ties observed red-flag indicators to the carrier's written referral criteria so the decision is traceable. It is designed to support consistent claim handling and an audit trail.
Who should complete the SIU referral decision worksheet?
It is typically completed by a claims adjuster, examiner, supervisor, or SIU liaison who has reviewed the file. The decision maker should be the person authorized to apply carrier criteria and sign off on the referral. If your process requires a second review, the worksheet can capture that in the additional review fields.
When should a claim be reviewed with this template?
Use it when a claim presents one or more indicators that may meet your carrier's SIU referral criteria, such as inconsistent statements, documentation gaps, or unusual loss patterns. It is also useful when a claim is borderline and needs a documented decision not to refer. The worksheet helps avoid informal, undocumented judgments.
Does this template replace the carrier's SIU policy or referral rules?
No. This worksheet records the decision against your existing carrier criteria; it does not define those criteria. You should link or reference the current policy, rule set, or internal guidance in the criteria reference field. That keeps the form aligned with the governing process.
What are the most common mistakes when using this form?
Common mistakes include listing red flags without explaining why they matter, leaving the criteria basis blank, and making a referral decision without a clear rationale. Another issue is collecting more claim detail than needed instead of using concise, relevant facts. The form works best when each field is specific and tied to the decision.
Can this worksheet be customized for different lines of business?
Yes. You can tailor the red-flag indicators, carrier criteria reference, and referral summary language for auto, property, workers' compensation, disability, or other claim types. The claim overview fields already support line of business and claim status, so the template can be adapted without changing the core decision structure.
How does this fit into an audit trail or claims system?
The worksheet creates a written record of the facts reviewed, the criteria applied, and the final decision, which can be stored with the claim file. It can be used as a standalone form or connected to a claims platform, document management system, or workflow tool. If your process requires approvals, the attestation and decision date fields help preserve accountability.
What should be included in the referral summary?
The referral summary should briefly state the key facts, the indicators observed, the criteria met, and the reason the matter was referred or held for more review. Keep it factual and avoid speculation or accusatory language. The goal is to make the decision understandable to a supervisor, auditor, or SIU reviewer.
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