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Run: 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 Invest...

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Submission Notice

Purpose of this submission

I confirm this submission is made for legitimate claims handling and SIU referral purposes only. (required)

Yes No N/A

Submission notes

Add any brief context needed for the audit trail. Avoid unnecessary PII.

Claim Overview

Claim number (required)

Date of loss (required)

Line of business (required)

Current claim status (required)

Reported by (required)

Brief claim summary (required)

Summarize the claim in 2-4 sentences. Keep the summary factual and avoid speculation.

Red-Flag Indicators

Red-flag indicators present (required)

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 (required)

Enter the policy, guideline, or procedure name used for the referral decision.

Does the claim meet written carrier referral criteria? (required)

Basis for criteria assessment (required)

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? (required)

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 (required)

Decision rationale (required)

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 (required)

Decision maker role (required)

Decision date (required)

Attestation (required)

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.

Yes No N/A

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