SIU referral decisions made at first notice — not at 60-day review.
Most SIU referrals happen too late — identified during adjuster investigation weeks into the claim, after habits of handling have been established and claimant expectations set. Fnolwise applies your SIU referral rules at FNOL, directing the claim to the right queue from the start.
Rule-based and pattern-based SIU referral logic
Fnolwise applies two complementary layers of SIU referral logic. Rule-based triggers are deterministic — a ClaimSearch hit count above threshold, a claim filed within a short tenure window, or an attorney representation noted at intake. Pattern-based signals are cumulative — individual flags that don't individually meet the referral threshold but collectively suggest elevated risk.
Hard referral rules
Certain signals trigger direct SIU routing regardless of other claim characteristics. Carriers define their own hard referral rules during pilot setup. Common hard rules include: three or more ISO ClaimSearch prior claim hits within a 36-month lookback; policy inception within 30 days of loss date on a high-limit policy; claimant asserting total loss on multiple policies for the same property.
Threshold accumulation rules
Multiple lower-weight signals are combined against a configurable threshold score. A claim with two prior ClaimSearch hits (below the hard rule threshold) plus an attorney indication plus a short policy tenure would accumulate enough weight to trigger the SIU routing threshold even without any single hard rule being met. The threshold score is configurable per line of business.
Line-of-business configuration
SIU referral thresholds differ between commercial property, commercial auto, and general liability. A prior claim pattern that is a hard referral rule for commercial auto may be a threshold-accumulation flag for commercial property. Fnolwise supports separate rule sets per line of business within a single carrier configuration.
TPA program-level configuration
For TPAs handling multiple program sponsors, SIU referral rules can be configured per program. A self-insured program sponsor may have more conservative SIU referral thresholds than a captive program. Fnolwise applies the correct rule set based on the program identifier associated with the incoming claim.
DOI timeliness requirements and SIU referral
Multiple state DOI regulations establish timeliness requirements that intersect with SIU referral timing. Understanding that regulatory context is part of designing a SIU routing rule set that functions within your compliance obligations.
Connecticut DOI — Reasonable promptness requirement
Connecticut DOI Regulation 38a-816 requires carriers to acknowledge claims within 10 business days of FNOL and to investigate and determine coverage within specified periods. SIU referrals routed at FNOL — rather than identified at the 30-day or 60-day adjuster review — support timely investigation initiation consistent with the reasonable promptness standard. Fnolwise is designed to support carriers' compliance with 38a-816; compliance obligations remain with the carrier.
Other state promptness standards
Florida, Texas, Ohio, California, and most other states with large P&C markets have analogous prompt payment and investigation timeliness regulations. While the specific timeframes vary by state, the principle is consistent: SIU referral decisions that occur weeks after intake add processing delay at the very beginning of the investigation timeline. Fnolwise's approach of routing at FNOL gives SIU investigators the maximum time available within the applicable regulatory window.
Triage record as SIU referral documentation
When a DOI examiner reviews claim files, the basis for SIU referral decisions is subject to scrutiny. Fnolwise writes the SIU referral rationale — which specific signals triggered the referral, under which configured rule or threshold — to the triage record that is written to your CMS at the time of the routing decision. This provides a contemporaneous, rule-based documentation trail for the referral, which supports examination readiness.
Handoff to adjuster and SIU teams
SIU routing at FNOL works within your existing adjuster workflow — it doesn't replace it. When Fnolwise routes a claim to the SIU queue in your CMS, the SIU investigator receives the triage record as part of the claim file: the ISO ClaimSearch result, the fraud flag indicators, the coverage verification output, and the referral rationale. The investigator does not start from a blank file.
For claims routed to enhanced handling (fraud-flagged but below SIU threshold), the assigned adjuster receives the same triage context. The adjuster can review the flag rationale and decide, within their claims authority, whether to escalate to SIU or proceed with standard investigation under heightened scrutiny. Escalation decisions by adjusters post-assignment are recorded in the claim file and do not bypass the original triage documentation.
Claims that clear the triage screening — no fraud flags, coverage confirmed in force, standard severity — proceed directly to the standard adjuster queue. The adjuster receives a triage record confirming the coverage verification result and severity band, so the first adjuster action is claim evaluation rather than coverage discovery.