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Fewer unnecessary referrals. Better evidence for investigators.

Across reviews claim evidence and referral rules as work arrives. Routine claims continue; cases needing a special investigation reach your team with the reasons and evidence assembled.

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Automated workflow

  1. System event

    New dashcam evidence arrives on claim HRM-26-B03. Across checks the referral rules and linked claims.

  2. Across

    Checked: Evidence and prior claims · Fraud indicators · Referral rules.

    Refer to investigators for review

  3. Sample claim · HRM-26-B03

    Offer on hold
    • Dashcam contradicts the account Rule A4 · within 1 business day Mandatory referral
    • Indicator score 6 of 13 indicators · referral at 6 points 16 points
    • Linked claims Same attorney, same treatment plan 3 claims

    No offer until the special investigation unit (SIU) manager approves.

    Referral drafted for the SIU manager.

    1. A4 Evidence contradicts the claimant: refer within 1 business day Referral rules
    2. R-12 Watch-list provider: add indicator points SIU guidelines, p. 6
    3. R-13 Open referral: hold offers and payments SIU interview 2

Too many flags. Too little context.

A fraud flag creates work for an investigator. When it arrives without the evidence or the carrier’s rules, the team must rebuild the case before deciding whether it deserves investigation.

01

Signals without the story

Scores and matches do not explain the evidence behind a suspicious pattern.

02

Rules outside the claim file

Referral criteria, watch lists, and expert knowledge sit in separate places.

03

Review spent on avoidable referrals

Investigators spend time checking cases that do not need a special investigation.

01 / Incoming flags
Provider mismatchProvider details differ between the claim and the record.
Repeated claim patternSimilar details appear in linked claims.
New claim evidenceA new document conflicts with the claim account.
03 / Investigator’s manual review

The investigator has to decide what needs investigation.

Evidence behind the flagMissing
Carrier referral ruleSeparate system
Prior claim contextNeeds tracing

They rebuild the case, check the carrier’s rules, and judge whether the referral is warranted.

Across keeps routine claims moving and focuses reviewers on what matters.

Across checks the evidence against your referral rules. Routine claims continue normal handling when those rules permit it. Mandatory referrals reach your special investigation unit (SIU) with the evidence and reasoning ready for review.

Claim HRM-26-B03

Referral required

The new evidence changes the referral decision.

  • Dashcam contradicts the accountRule A4 · within 1 business dayMandatory referral
  • Indicator score6 of 13 indicators · referral at 6 points16 points
  • Linked claimsSame attorney, same treatment plan3 claims
Evidence package for the investigator

The applicable rule, new evidence, and linked claims travel with the referral.

Built from how you investigate.

Much of your referral judgment lives with your investigators, not in the fraud score. The Architect reads your manuals and past claims, then asks your investigators about the gaps.

  1. Manuals, referral rules, past claims, and your investigators’ answers.

    • Fraud indicators
    • Referral rules
    • Authority matrix
    • SIU interviews
    • Architect asks:Can the adjuster make an offer during an SIU referral? SIU investigator answers:No. Hold offers and payments until the SIU manager approves.

  2. The Architect drafts plain-language rules from those sources. Your SIU lead reviews them.

    • A4 Referral rules Evidence contradicts the claimant: refer within 1 business day
    • R-12 SIU guidelines, p. 6 Watch-list provider: add indicator points
    • R-13 SIU interview 2 Open referral: hold offers and payments
    • R-20 State reporting rules NY or TX: start the 30-day clock

  3. A versioned graph that links each evidence check to a draft action and a human review.

    • Check Claim evidence · Referral trigger · Indicator score
    • Draft SIU referral · Rule trace · Offer hold
    • Review Adjuster confirms · Manager approval · Logged decision

  4. The Operator catches rule changes. Past claims re-run before your team approves the change.

    • Low damage, high medical bills Referred
    • Late-reported claim Referred
    • Demand above reserve Held for approval
    • Claim HRM-26-B02: was no SIU action, now SIU consult Past claims re-run ·Awaiting SIU approval

How we’ll measure the pilot.

Targets we agree with you before the build, scored on claims your SIU already decided.

Your SIU reviewers rate each referral the system makes, and we compare the rate with your adjusters’ referrals.

Every referral and non-referral records the rule and data behind it.

Apply a real rule change and re-run the pilot claims without engineering work.

Questions to askCheck the answer against your own cases

Questions to ask any fraud AI vendor.

  1. Does it know what isn’t in the fraud score?

    Why it matters: Most referral rules live in manuals, authority rules, and your investigators’ judgment.

    Across: The rulebook is built from all of it, not just the score.

  2. Does it catch new schemes early?

    Why it matters: Models that learn from confirmed cases see a new scheme late.

    Across: An investigator describes the pattern in plain language. It runs as a rule without waiting for confirmed cases.

  3. Why it matters: Thresholds, watch lists, and reporting rules change. Each change can’t become an engineering ticket.

    Across: Describe it in plain language. It’s tested on past claims and approved first.

    • Provider watch list: one clinic added
    • Claim HRM-26-B02: no action to SIU consult
    • Past claims re-run , awaiting approval

  4. Can you trace every referral decision?

    Why it matters: Regulators and your SIU need the reason behind each referral and each non-referral.

    Across: Every referral decision and offer hold is logged with its rule and source data.

Start with your past claims.

A three-week pilot on your past claims, scoped to one line of business.

  1. Week 1
    • Manuals, indicators, and referral rules
    • 50–100 past claims with SIU outcomes
    • Two recorded SIU interviews
  2. Week 2
    • Writes the rulebook in plain language
    • Your SIU lead reviews it
    • Runs past claims through the workflow
  3. Week 3
    • Tested on held-out claims with SIU outcomes
    • Misses and rule changes reviewed
    • Results against the agreed targets
  4. Your decision

    Use the results to decide whether to connect your claims platform, SIU case management, and adjuster channels.

What we need to start.

  • Claims manual Coverage, handling, and reserve rules
  • Fraud indicators The list, with points and thresholds
  • Referral rules Triggers, timing, and state reporting rules
  • Authority matrix Who approves what, at which thresholds
  • 50–100 past claims With the SIU outcome for each
  • Two recorded interviews With your SIU investigators
How it connectsPermissions, approvals, and your systems of record

Across runs where the work happens.

Your systems trigger the process and remain the source of truth. Across returns the result to the operational workflow, with a review package when a person needs to decide. The integration and review interface are configured for your use case and existing systems.

Work arrives

New claim, document, or claim update

  • Claims platform
  • Policy admin
  • SIU case management

Across

Context.
Rules.
Decision.

Sources attached

Routine work

Continue normal claim handling, within the configured controls.

Ready for review

Evidence package for investigators, with the reasoning and evidence ready.

across / new run start here

Let us help you get work done.

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