Insurance Claims Triage Automation: Governed 30‑Day Plan

```yaml
policy_version: 1.3
owners:
  claims_ops: "Director, Auto Claims Intake"
  risk_compliance: "Sr. Manager, Compliance & SIU Liaison"
approvers:
  - role: "VP, Claims"
  - role: "Deputy CISO"
regions:
  - code: US-CO
  - code: US-TX
residency:
  cloud: aws
  region: us-east-1
  endpoints:
    llm: "arn:aws:bedrock:us-east-1:acct:model/anthropic.claude-vpc"
    vision: "arn:aws:sagemaker:us-east-1:acct:model/claims-vision-private"
  never_train_on_client_data: true
sources:
  - name: guidewire_claimcenter
    type: api
  - name: fnol_portal
    type: webhook
  - name: o365_fnol_inbox
    type: email
  - name: genesys_calls
    type: transcript
  - name: s3_documents
    type: bucket
slo:
  triage_decision_time_p95_minutes: 12
  override_rate_max: 0.15
queues:
  - name: AUTO_PD_STANDARD
  - name: AUTO_TOTAL_LOSS
  - name: AUTO_GLASS
  - name: SIU_REVIEW
routing_rules:
  severity:
    model: "claims-vision-private"
    thresholds:
      critical: { min_confidence: 0.85, route: AUTO_TOTAL_LOSS }
      major:    { min_confidence: 0.80, route: AUTO_PD_STANDARD }
      minor:    { min_confidence: 0.75, route: AUTO_GLASS }
    hilt_required_below_confidence: 0.80
  siu_risk:
    model: "anthropic.claude-vpc"
    features:
      - injury_claimed
      - late_report_days
      - prior_claims_24m
      - geo_hotspot
      - inconsistent_story
    thresholds:
      refer_auto: { score_min: 0.70, confidence_min: 0.80, route: SIU_REVIEW }
      suggest_review: { score_min: 0.55, confidence_min: 0.70, notify: "SIU_CHANNEL" }
    exclusions:
      - catastrophe_event: true
      - policy_tenure_years: 
          min: 5
          reason: "Deprioritize long-tenured low-risk accounts unless other signals high"
  vendor_routing:
    glass:
      criteria: ["minor", "front_windshield"]
      route: AUTO_GLASS
    body_shop:
      criteria: ["major", "panel_damage"]
      preferred_network: "DRP-NORTH-TEXAS"
      route: AUTO_PD_STANDARD
human_in_the_loop:
  triggers:
    - high_est_loss_amount_usd: 
        min: 15000
    - low_confidence_any: true
    - coverage_dispute_flag: true
  approver_role: "Claims Supervisor"
audit_logging:
  enabled: true
  destination: snowflake
  schema: claims_triage_decisions_v3
  fields: [inputs_hash, model_scores, confidence, reason_codes, human_override, final_route, timestamp]
change_control:
  approval_required_for:
    - thresholds.siu_risk
    - thresholds.severity
  ticket_system: jira
  change_window_utc: "01:00-03:00"
observability:
  metrics_namespace: "claims.triage"
  monitors:
    - name: "p95_decision_latency"
      threshold_ms: 720000
    - name: "override_rate"
      threshold: 0.20
    - name: "siu_precision"
      threshold: 0.80
retention:
  decision_logs_years: 7
  pii_redaction: true
  export_capabilities: [pdf_report, csv, json]
controls_map:
  nist_ai_rmf: ["Explainability", "Human Oversight", "Robustness"]
  soc2_trust: ["Security", "Availability", "Confidentiality"]
```

{
  "title": "Insurance Claims Triage Automation: Governed 30‑Day Plan",
  "published_date": "2025-11-28",
  "author": {
    "name": "Lisa Patel",
    "role": "Industry Solutions Lead",
    "entity": "DeepSpeed AI"
  },
  "core_concept": "Industry Transformations and Case Studies",
  "key_takeaways": [
    "Start in one line of business with a clear SLO (e.g., p95 triage in 12 minutes) and a human-in-the-loop safety gate.",
    "Route by risk, severity, and coverage using a policy file; keep SIU referrals auditable with a decision ledger.",
    "Prove value fast: measure FNOL-to-assignment time, adjuster hours returned, SIU false positives, and leakage proxies.",
    "Satisfy compliance with prompt logging, RBAC, data residency, and model access via a trust layer that never trains on client data.",
    "Use the 30-day audit → pilot → scale motion to secure cross-functional buy-in and lock in measurable wins."
  ],
  "faq": [
    {
      "question": "How do we avoid over-referring to SIU?",
      "answer": "Set a precision floor and require human approval when scores are borderline. We monitor SIU precision weekly and treat policy changes as governed change requests with rollback."
    },
    {
      "question": "Where does this run and who can see the logs?",
      "answer": "In your cloud VPC or on-prem. Logs land in Snowflake with RBAC tied to AD/Okta groups. Compliance and SIU have read access; supervisors can export evidence for audits."
    },
    {
      "question": "What if a regulator asks why a claim wasn’t flagged?",
      "answer": "The decision ledger stores inputs, scores, confidence, and override reasons. You can replay any triage decision and show approval lineage and model versions."
    }
  ],
  "business_impact_evidence": {
    "organization_profile": "Regional Auto P&C carrier on Guidewire ClaimCenter; AWS-first with Snowflake",
    "before_state": "Manual tag-and-route via inbox and spreadsheet queues; 9.2h p95 FNOL-to-assignment; SIU precision 54%; frequent overtime during surge events",
    "after_state": "Governed triage with human-in-the-loop; 3.6h p95 FNOL-to-assignment; SIU precision 82%; automated vendor routing",
    "metrics": [
      "61% faster p95 assignment (9.2h → 3.6h)",
      "13,800 analyst hours returned annually",
      "SIU false positives reduced 48%",
      "Overtime down 22% in surge months"
    ],
    "governance": "Legal/Security approved because the system ran in a VPC with data residency controls, full prompt/decision logging, strict RBAC, human-in-the-loop for high-dollar/low-confidence cases, and models never trained on client data."
  },
  "summary": "Automate claims triage with governed AI in 30 days—faster assignment, fewer escalations, RBAC, prompt logging, and data residency to satisfy compliance."
}