Before a new claims reviewer approves a single settlement or decline the agent has prepared, they should complete twelve checks: restricted access, signed red lines, shadowing on held claims, the shared foundation, reviewer modules and exam, a practicum that includes a decline and a suspected fraud, an incident drill, and a sign-off that sets their payment limit.
Where does a claims reviewer sit in the agent's work?
A claims agent takes the first notification, checks the policy is in force, compares the loss to the cover, gathers documents, flags fraud indicators and drafts either a settlement offer or a decline letter. Most of that is depth 1 to 3. Paying the claim is depth 4: money leaves and is hard to recover. Declining is not a payment, but it is a decision with large consequences for the policyholder, so it should be held for a person in every case.
The reviewer therefore meets two streams. Held payments, where the questions are whether the amount is right and the payee is who they claim to be. And held declines, where the question is whether the policy wording really excludes this loss. A reviewer who trusts the agent's reading of an exclusion without opening the wording has stopped reviewing. The checklist is built to stop that habit forming.
How do you work through the checklist?
The claims team manager holds the master copy and signs each line. The reviewer keeps their own copy and adds notes. Lines 1 to 3 happen before day one; lines 4 to 9 take roughly seven weeks; lines 10 to 12 close it off. The order follows the guide to training teams for AI agents: certify the people who handle held actions before giving them approval rights.
If you are new to formal onboarding, what onboarding is explains the basic idea. The detailed teaching method for claims is in how to train the claims team to review AI agent decisions.
The checklist
Each line has a space for the date and the signature of the person confirming it.
- Access. Read-only workspace access; no payment or decline rights. Signed by: claims manager
- Agent profile. Reviewer has read the agent's capabilities: notification and triage (1), document gathering (3), settlement draft (2), payment (4, held), decline letter (2, always held). Signed by: reviewer
- Red lines. Signed: never approve a decline without reading the policy wording; never pay to bank details supplied only by a third party; never approve a claim on your own policy or a relative's. Signed by: reviewer and manager
- Shadowing. Two days with a certified reviewer, covering at least one decline and one held payment. Signed by: buddy
- Fraud indicators. Walked through the agent's fraud flags with the fraud team, and what each one does and does not mean. Signed by: fraud lead
- Shared foundation. Completed, test passed. Signed by: learning lead
- Reviewer modules and exam. Completed and passed. Signed by: learning lead
- Practicum. Two weeks of real held claims, each confirmed by a buddy before release. Signed by: buddy
- Practicum coverage. Includes a decline, a suspected fraud, a payee change and a claim near the reviewer's future limit. Signed by: claims manager
- Incident drill. Taken part in a drill where the agent's certificate lapses mid-day. Signed by: claims manager
- Assessor sign-off. Practicum reviewed: no missed red line. Signed by: assessor
- Approval rights and renewal. Payment limit set; decline rights granted or withheld for an initial period; renewal date entered. Signed by: claims manager
What does a completed checklist look like?
An illustrative home insurer's claims team welcomes Sample Reviewer K, moving across from customer service. The agent pays escape-of-water claims up to 2,000 at depth 4 within bounds and holds everything above, plus every decline.
Lines 1 to 3 are signed on her first morning. While shadowing, she watches a buddy reverse the agent's draft decline: the agent had read a wear-and-tear exclusion as applying, but the surveyor's report attributed the damage to a sudden pipe burst. The fraud lead walks her through why a flag for "recent policy inception" is a prompt to look, not a reason to decline.
Her practicum in weeks 6 and 7 covers 90 held claims. She holds a payment where the policyholder's email asked for funds to go to a builder's account; she verifies it by calling the policyholder on the number on file. Sign-off comes at the end of week 7 with a payment limit of 10,000 and decline rights after a further month of second review.
Where the Academy fits
Pryme Intelligence Academy delivers lines 6, 7 and 11. Operator certification means a 60-minute, 40-question exam passed at 32 of 40, then a two-week practicum of real review decisions with at least 95 in every 100 correct and no missed red line, signed off by a Pryme assessor. The certificate lasts 12 months and is renewed with an update module and a short quiz.
Questions people ask
Should claims reviewers take decline rights straight away?
It is safer to stagger them. Payments can be capped by amount; declines cannot, so a short period of second review on declines is a sensible practice for new reviewers.
Who sets up the reviewer's access?
Usually IT, on the claims manager's request. The IT team's own reviewers follow a different path, set out in the reviewer onboarding checklist for the IT team.
Can this checklist be used for claims operations staff who do not decide claims?
Use a lighter version. Staff who handle documents and payments after a decision fit better with the reviewer onboarding checklist for the operations team.