What this guide is for
O*NET places claim review, investigation, claim-record work, settlement work, and communication inside this occupation. Those are consequential professional functions, not safe defaults for a general-purpose model. This field manual gives AI a smaller clerk role: make the evidence gaps, source versions, and human authority visible before any authorized person decides what happens next.
Make one review packet, not a synthetic claim move
needs_review.Bound the scenario and authority.
Use a fictional or organization-approved scenario. Name the claims authority owner and the jurisdiction, line/product, policy/plan, privacy, records, and legal/compliance reviewers needed. Stop for a live claim file, private information, or a requested decision/action.
Inventory only approved source labels.
AI may record the source label, owner, date/version, and stated permitted use. It must not determine whether a source establishes coverage, liability, causation, fraud, damages, a reserve, or a payment.
Make every gap explicit.
When an authority, version, source, or approval is missing or conflicts, write
unknown. Do not fill the gap with model memory, an assumed deadline, or a plausible claim narrative.Draft questions, never findings.
Prepare neutral questions for the named claims, legal/compliance, jurisdiction/licensing, privacy/security, records, and model/vendor-risk reviewers. Do not draft a settlement, denial, payment, notice, or claimant communication.
Hand off and stop.
Create the local packet and allow the named reviewer to approve, revise, reject, or escalate it. The packet never authorizes an investigation, determination, communication, claim-system change, or payment.
Give AI a clerk job, never a claims-professional job
Organizes approved source labels, owners, dates, versions, and stated uses.
Flags missing, stale, duplicate, unsupported, or conflicting material without resolving it.
Drafts neutral reviewer questions tied to named human authority.
Safe preparation vs. approval-required work
| AI may prepare | Authorized human must decide or do |
|---|---|
| Inventory organization-approved source labels and metadata | Access a claim file or choose/apply a source to a claim |
| Flag missing, stale, duplicate, unsupported, or conflicting support | Investigate, assess people/evidence, or determine coverage, liability, causation, fraud, damages, or status |
| Produce an unknown log and neutral reviewer questions | Set a reserve; calculate valuation, benefit, payment, settlement, or denial; interpret policy/legal requirements |
| Assemble a local review-only receipt | Communicate externally, update a claim system, pay, report, or take any external action |
NAIC materials provide regulatory context, not a universal jurisdiction or carrier rule. State adoption, product/line, carrier procedure, license/authority, and the controlling source must be verified before any non-fictional use.
Five ways a preparation tool becomes an unsafe claims tool
- Calling a summary an investigation. A clean source list is not evidence weighing, fact finding, or claim handling.
- Turning an unknown into a conclusion. A missing source/version/authority cannot become coverage, liability, fraud, damages, reserve, or payment through model confidence.
- Borrowing a rule from the wrong place. A NAIC model, a different line, an old policy edition, or another jurisdiction is never a controlling live claim rule without authorized confirmation.
- Adding private data “to help.” Do not paste claim, policy, medical, financial, image, payment, credential, or system data into a general-purpose tool without a separately authorized process.
- Letting a draft become an action. The packet ends at
needs_review; it cannot investigate, decide, calculate, message, update, pay, or send.
Claim Evidence & Review Desk
Enter only fictional or organization-approved, minimum-necessary text. This form stays in the browser and creates a review-only receipt; it does not send or save anything.
What this manual is built on
- O*NET: Claims Adjusters, Examiners, and InvestigatorsOccupation context; not permission to conduct claims work.
- BLS: Claims Adjusters, Appraisers, Examiners, and InvestigatorsBroad U.S. role context; authority and licensing remain jurisdiction-specific.
- NAIC: Artificial IntelligenceCurrent insurance AI and human-review context.
- NAIC: AI Model Bulletin announcementGuidance context, not a model law or jurisdiction rule.
- NIST AI 600-1Voluntary generative-AI risk-management framing.
The cited sources and the guide boundaries should be rechecked before real-world use.
Connect this desk without blurring authority
Use the proposed Claims & Policy Service Evidence Desk for intake/service boundaries, the Auto Damage Appraiser Desk for vehicle evidence, and the Insurance Underwriter Desk for pre-decision underwriting evidence. These routes are proposals only until separately approved and integrated.