An SIU referral that cannot be explained — in writing, in the claim file, by reference to documented criteria — is a referral that exposes the carrier to two different types of risk. The first is investigative: an SIU case built on an undocumented intake referral lacks the documented chain of custody that makes investigative findings usable. The second is regulatory: state insurance departments increasingly scrutinize whether SIU referral practices reflect consistent, documented criteria rather than adjuster intuition applied inconsistently across the book of business. Both risks have the same remedy: a rule set that defines referral criteria in advance and a system that applies those criteria to every FNOL automatically.
What a Defensible SIU Rule Set Contains
SIU routing logic should be documented before the first claim is processed against it, not inferred from historical referral patterns. A defensible rule set specifies, for each line of business the carrier writes, the conditions that trigger each referral outcome: standard handling, enhanced handling, SIU-eligible queue, and mandatory SIU referral. The distinctions between these tiers matter:
- Standard handling: No fraud indicators identified at FNOL. Claim proceeds to adjuster assignment per normal routing.
- Enhanced handling: One or more soft indicators present (late reporting, policy age, ClaimSearch soft hit) that do not meet referral threshold but warrant documented adjuster attention. The file notes the indicators and the determination that referral threshold was not met.
- SIU-eligible: One or more indicators present that exceed the carrier's soft-threshold but where the referral decision is subject to supervisor review. This tier is appropriate for indicators that are individually ambiguous but collectively significant.
- Mandatory SIU referral: Indicators that automatically trigger referral without discretionary review — a ClaimSearch match showing prior fraud notation, a loss pattern that matches a known ring indicator, or a staged-accident flag based on incident circumstances.
Documenting these tiers and the criteria for each is not purely an operational exercise. Many state insurance fraud bureaus and DOI regulations require carriers to maintain SIU programs with documented referral procedures. Connecticut's fraud reporting obligations, like those in most states, require a documented investigation process. An intake-level referral rule set is the first link in that documented chain.
ISO ClaimSearch Thresholds in the Rule Set
ISO ClaimSearch results are the most structured input into SIU routing logic at FNOL. The ClaimSearch return for a given claimant or policy includes the number of prior claims, the lines of business, the approximate dates, and any existing SIU notations. Translating those results into routing decisions requires configured thresholds.
A common framework used by regional P&C carriers maps ClaimSearch results to routing outcomes as follows: zero prior claims on the policy within a 36-month look-back — no flag; one prior claim on the same loss category within 24 months — note in file, proceed to standard handling with documentation requirement; two or more prior claims on the same loss category within 36 months — route to SIU-eligible queue; any existing SIU notation in the return — mandatory SIU referral, suspend adjuster assignment pending SIU initial review. These specific threshold numbers are illustrative. The principle is that thresholds should be written down, configured in the intake system, and applied uniformly.
The line-of-business dimension of ClaimSearch thresholds matters. A bodily injury claimant with two prior BI claims on auto losses within three years presents a different risk profile than a commercial property insured with two prior property losses on different premises. The routing rule should account for whether the prior claims are on the same loss category as the current FNOL, not just the raw count of prior claims in the database.
Line-of-Business Flags
Beyond ClaimSearch, line-of-business characteristics create their own triage signals. Commercial auto claims involving catastrophic injury to third parties should be reviewed early for coverage adequacy and potential bad-faith exposure, regardless of fraud indicators. Personal auto FNOL submissions from IVR or portal channels that claim bodily injury without any description of medical treatment should be flagged for inside adjuster review before BI reserves are set. Commercial property claims involving total loss should route to field adjuster rather than inside adjuster by default, with SIU notification if the total loss is reported within the first policy year.
Workers' compensation first reports of injury (FROI), governed by ACORD 22, have their own SIU flag categories: Monday-morning injuries that were allegedly sustained on Friday, injuries reported by the claimant without employer corroboration, and claimants with prior workers' comp claims at different employers within a short window. While workers' comp is a distinct line from commercial property and auto, carriers writing commercial lines that include comp exposure should have a consistent FROI fraud screening protocol that operates by the same documented-criteria principle.
Reporting-Party Patterns
The identity and relationship of the reporting party to the claim is a triage signal that is often overlooked in intake design. FNOL submitted directly by the claimant, submitted by the claimant's attorney, submitted by an agent, and submitted by a third party acting on the claimant's behalf each carry different risk profiles for certain loss types. An attorney-represented claimant reporting an auto bodily injury on the same day as the alleged incident is a pattern that warrants flagging for the adjuster; attorney involvement that early in a claim's lifecycle is unusual for minor injuries.
Third-party auto submissions where the reporting party is not the policyholder or a named insured — someone claiming property damage caused by the insured — present the standard third-party FNOL challenge, but the reporting-party field should be captured and documented as part of the routing analysis. ACORD 2 includes a field for the reporting party's relationship to the insured; an FNOL intake system that captures and records this field enables routing logic that considers reporting-party type as a signal.
Documentation: The Decision Trail That Must Survive Investigation
When a claim that was routed to SIU at intake proceeds to a denial, a NICB referral, or a civil suit against the claimant, the claim file's intake record is the first chapter of the investigative story. The intake routing decision — and the documented basis for it — is reviewed by SIU investigators, outside counsel, and potentially by insurance fraud bureau investigators. If the routing decision at intake was generated by a system applying documented criteria, those criteria can be articulated. If the routing decision was made informally based on an intake representative's judgment, the documented trail ends at "referred to SIU by intake."
We are not saying that adjuster and intake representative judgment has no role in SIU referrals. Experienced claims professionals identify patterns that no rule set fully anticipates. What the documented rule set provides is a baseline that ensures consistent coverage of known fraud indicators, so that the exercise of human judgment is additive rather than the primary mechanism. An adjuster who overrides the system to refer a claim that scored below the referral threshold — because something about the incident description doesn't add up — should document that override and the basis for it, just as the system documents the automated routing decisions it makes.
The SIU referral that holds up in investigation is the one where the claim file shows, from the first line of the intake record: what ClaimSearch returned, which criteria the submission matched, and which routing tier was assigned. Carriers who want to review their current SIU routing logic against this standard can connect with the Fnolwise team.
