# Medical Record Review Prompts for Claims Adjusters > Seven prompts for claims adjusters: a 400-word exposure summary, billing by provider, causation strength rating, investigation flags and value factors. Canonical page: https://medrecords.ai/content-hub/prompt-library/medical-record-review-prompts-for-claims-adjusters/ --- [Content Hub](https://medrecords.ai/content-hub/) › [Prompt library](https://medrecords.ai/content-hub/prompt-library/) › Medical record review prompts for claims adjusters 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. By [Ahmed Jemaa](https://medrecords.ai/authors/ahmed-jemaa/) , Co-Founder & CEO of Medrecords AI · Published 8 Sep 2026 The job Understand the file well enough to set a reserve and evaluate exposure, quickly, and know when to go deeper. Produces Reserve setting, exposure evaluation, settlement authority recommendation, triage decisions. Spine priority S1, S5, S9, S13, S14, S18, S21, S22. This lane runs the smallest spine subset and does so deliberately. Run order S1 and S5, then A1 for the picture, then A2 and A4 for the numbers and the causation view, then A5 to decide whether the file needs a fuller review. If A5 fires, escalate to the full spine or route to Lane 2. ### The prompts Run these after the spine prompts marked priority above. Placeholders in angle brackets need filling in. A1 #### One-page exposure summary Summarize in under 400 words: incident, claimed injuries, treatment duration and intensity, current documented status, work loss, and the principal causation question. Cite the key documents only. The word limit is functional. An exposure summary that runs to six pages is not doing the job this lane needs. A2 #### Billing summary by provider Total billed charges by provider and by treatment category. Present as a table: provider, specialty, date range, encounter count, billed total. Flag providers with billing but incomplete records. A3 #### Treatment proportionality Compare documented treatment duration and intensity against the documented injury severity and objective findings. Report the comparison as an observation with citations. A4 #### Causation strength For each claimed injury, state what the records establish about causation, rate the record support as strong, moderate, or weak, and cite the basis for the rating. Identify the injuries where causation is most contested. The rating is a triage instrument, not a conclusion. It tells you where to spend the next hour. A5 #### Investigation flags Identify record features warranting further investigation: unexplained gaps, treatment timing patterns, inconsistent histories, prior injury indicators, referral patterns. Present as a prioritized list with citations. Report observations, not conclusions. The neutral-report clause carries real weight in this lane, for the reason in the responsibility note below. A6 #### Prior claim indicators Identify any reference in the records to prior injuries, prior claims, prior litigation, or prior treatment of the same body regions. Cite each. A7 #### Settlement factor extraction Extract the documented factors bearing on value: permanency statements, impairment ratings, work restrictions, future care recommendations, and MMI status. Present as a table with citation and date for each. **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. 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