Prompt library
Medical record review prompts for claims adjusters
Medical record review prompts for claims adjusters are built for triage rather than depth: a 400-word exposure summary, billing totalled by provider, and a causation strength rating that tells you where the next hour goes. One prompt decides whether the file needs a fuller review at all.
The prompts
Run these after the spine prompts marked priority above. Placeholders in angle brackets need filling in.
One-page exposure summary
The word limit is functional. An exposure summary that runs to six pages is not doing the job this lane needs.
Billing summary by provider
Treatment proportionality
Causation strength
The rating is a triage instrument, not a conclusion. It tells you where to spend the next hour.
Investigation flags
The neutral-report clause carries real weight in this lane, for the reason in the responsibility note below.
Prior claim indicators
Settlement factor extraction
Lane failure mode: speed plus the confident partial. This lane is built for velocity, which is exactly the condition in which an incomplete record set produces a confident wrong number. One habit fixes most of it: run S4 even here, and note the production date on every reserve memo. A reserve set on a partial file should say it was set on a partial file.
Professional responsibility. This is the lane where verification tier and legal exposure connect most directly.
The NAIC adopted the Unfair Claims Settlement Practices Act as a free-standing model in June 1990, and most states have since enacted something substantially similar. Among the practices it addresses is the failure to adopt and implement reasonable standards for the prompt investigation of claims. Whatever your state's version says precisely, the through-line is that the investigation itself is regulated, not only the outcome.
That is the frame to hold. A fast, confident, wrong reading of an incomplete record set is an investigation defect, and it is a defect that lives in the file. "The system flagged it" is not a defense, and a reserve memo that does not say it was set on a partial production is a document you would rather not be shown later.
Any finding that moves a decision gets verified against the source. The observation-not-conclusion phrasing throughout this lane exists so the human judgment stays visibly with the human, which is both the better practice and the better record. State statutes vary substantially in scope and in whether they support a private right of action, so the specifics are a question for your own compliance function. ---
Lane failure mode: speed plus the confident partial
This lane is built for velocity, which is exactly the condition in which an incomplete record set produces a confident wrong number. One habit fixes most of it: run S4 even here, and note the production date on every reserve memo. A reserve set on a partial file should say it was set on a partial file.
Professional responsibility
This is the lane where verification tier and legal exposure connect most directly.
The NAIC adopted the Unfair Claims Settlement Practices Act as a free-standing model in June 1990, and most states have since enacted something substantially similar. Among the practices it addresses is the failure to adopt and implement reasonable standards for the prompt investigation of claims. Whatever your state's version says precisely, the through-line is that the investigation itself is regulated, not only the outcome.
That is the frame to hold. A fast, confident, wrong reading of an incomplete record set is an investigation defect, and it is a defect that lives in the file. "The system flagged it" is not a defense, and a reserve memo that does not say it was set on a partial production is a document you would rather not be shown later.
Any finding that moves a decision gets verified against the source. The observation-not-conclusion phrasing throughout this lane exists so the human judgment stays visibly with the human, which is both the better practice and the better record. State statutes vary substantially in scope and in whether they support a private right of action, so the specifics are a question for your own compliance function. ---
Issues to raise, not answers. Requirements vary by jurisdiction, and none of this is legal advice.
Run these on a file you already have
Send one real record set. You get back a cited chronology, and you review it, you revise it, you sign it.