Delegated claims audit on every file a TPA touches, as it moves — not a sample a year after payment
Every delegated claim reviewed, not a sample a year after payment.
See one case, screen by screen ↓Software that lets a carrier or managing agent oversee the claims its delegated administrators handle under their own authority. Delegated Claims Audit reads every file event a TPA posts — notes, reserve changes, payments, letters — as it lands and runs seven checks on it, instead of sampling files at an annual audit.
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When a carrier hands claims authority to a TPA, what comes back is a line on the monthly claims bordereau, not the file. The adjuster’s notes, the reserve history, the invoices and the letters stay in the administrator’s claims system. The carrier sees them when an auditor goes on site and pulls a sample.
That audit reads a few hundred files, months after payment. By then an overpayment has cleared, a contractor has been paid the same line twice, a reserve has sat below paid for a quarter, and a claim that should have been reported as a large loss has never reached the carrier’s desk. The finding goes into next year’s audit letter, and recovery is a negotiation instead of a credit on the next invoice.
Estimated split. The total by hand matches the ≈ 7 months the working solution shows for findings that wait for an audit; with the solution, the hero claim is flagged the morning of the payment and Bramblecrest’s answer is due two days later.
Seven agents read every file event a TPA posts and run seven checks on it; the claims manager decides.
Monday 12 October, 10:42. Bramblecrest Claims Services, a Tampa TPA handling the Coastal Habitational Property program for Harrowgate Specialty, issues a $68,400 check on a water-damage claim. Here is what happens next, screen by screen, in the working solution.
Claire opens the file stream: every note, reserve, payment and letter her five administrators post, checked as it lands. The strip above it counts the file events checked today, 37 claims flagged this week and 9 reportable claims open, 3 of them overdue. Beside each TPA sits its live score per check over the last 30 days and its leakage estimate for 2026.
“Agents read and check · you decide every hold, referral and finding.”
Bramblecrest pays Gulfline Restoration LLC $68,400 on invoice GR-11402 — the rebuild of units 3B, 2B and 1B at Linden Court Apartments, claim HB-26-08812. Seven badges evaluate on the row in front of her. Contact, coverage and diary pass. Reserve, payment and report turn red, and the authority check is still running.
Authority checker: “$74,600 paid against $50,000 · no referral, no Harrowgate approval on file.”
Claire clicks the authority badge. The drawer shows the payment ledger entry with “referral to carrier: none” highlighted, the adjuster’s 10:38 note — “Supervisor approved full invoice.” — the numbers, and the rule it applied: binder HSI-BA-2026-0417 §3.2, $50,000 indemnity per claim, anything above referred for prior written approval.
“$74,600 is now paid on this claim — $6,200 on 2 Jul and $68,400 today — against $50,000 of settlement authority.”
The claim opens on its money: $74,600 paid, $24,600 above authority, the indemnity reserve still $45,000 and $29,600 below paid. Gulfline’s $71,250 rebuild estimate of 2 Oct implies at least $83,650 incurred. The same estimate took the claim over the $35,000 large-loss notice threshold; the notice was due Tue 6 Oct and never came.
The payment checker matched all six lines of GR-11402 against the two earlier invoices. Line 4 — structural drying, 6 days, 9 air movers, 3 dehumidifiers, $6,200 — is the same line paid on GR-10977 on 2 Jul. The leakage estimator adds $6,200 to Bramblecrest’s 2026 estimate, now $412,300.
“Same line, paid twice. Structural drying for the same 6 days, the same 9 air movers and 3 dehumidifiers — $6,200 on 2 Jul and again today.”
Claire places a payment hold: any new payment on HB-26-08812 now needs her approval before Bramblecrest issues it. Then she opens the request drafted from the file, to Tom Gaffney, Bramblecrest’s claims team lead: a written referral, a corrected indemnity reserve and Gulfline’s credit for the duplicate drying line, by Wed 14 Oct.
Drafted from the file — she edits it before it is sent.
The notice is already drafted: policy, binder, loss, $74,600 paid, the $45,000 reserve against $83,650 incurred implied by the file, both triggers — likely above $35,000 since Fri 2 Oct, above authority today — and the open items. Claire logs it to Harrowgate claims, with a copy for Priya Raman in reserving.
The finder drafts every notice. It never sends one without the claims manager.
Claire records the $6,200 duplicate for recovery, and it tops the findings ledger: Linden Court, duplicate payment, “GR-11402 line 4 repeats GR-10977 line 1”. The 2026 estimate now stands at $1,083,500 on $47.8M paid through five administrators, with $312,800 recovered. Only findings the claims manager accepted are counted.
The reportable list carries the nine open claims with their trigger, the date it was met, the notice due date and who it goes to. Linden Court now shows its notice logged. Cypress Hollow — a suit filed 29 Sep — and Marigold Café — open more than six months — are still overdue; two reinsurance notices for Ashgrove Re are drafted and waiting.
The scorecards show each administrator’s pass rate per check, days to close, reserve accuracy and leakage as a share of paid. Bramblecrest’s within-authority score has dropped to 98% after today’s payment, and every one of its files is reviewed — the last on-site audit read 6%.
The same claim, seen by the carrier’s head of delegated claims, its auditor, its reserving analyst — and the TPA’s own team lead.
Seven agents read every file event a TPA posts and run seven checks on it; the claims manager decides.
Reads every note, reserve change, payment, letter and report the administrators post, and the monthly claims bordereaux; ties each event to its claim, policy and binder.
Confirms the policy was in force on the loss date, the cause of loss is covered under the binder, and deductibles and sublimits are applied; flags reservations of rights, declinations and declined tenders made without the carrier’s agreement.
Watches reserves against the latest estimate, demand or report in the file: initial reserve within 5 business days, within 15% of the latest estimate, reviewed within 10 business days of new information, never below paid. Computes the incurred the file implies.
Sums paid and reserved indemnity and expense per claim, compares them with the administrator’s authority for that binder, and looks for a referral or carrier approval on the file.
Checks the payee against the vendor list, the invoice arithmetic, the deductible, and every invoice line against every prior payment on the claim.
Applies the reporting triggers — likely above the notice threshold, above authority, coverage dispute, suit, open more than six months — starts the 2-business-day clock and drafts the notice from the file.
Prices each finding — duplicate, deductible, outside coverage, vendor rate, missed subrogation, expense above guidelines — and sums leakage per administrator and cause.
Decides; a second approver changes authority. The agents propose; a named person decides.
Ask in plain words about a claim, an administrator, a check or the leakage. Every answer cites the file.
Why did Bramblecrest’s authority badge turn red on Linden Court?
At 10:41 Bramblecrest paid $68,400 to Gulfline Restoration on invoice GR-11402. With the $6,200 paid on 2 Jul, $74,600 is now paid on HB-26-08812 against $50,000 of settlement authority on binder HSI-BA-2026-0417 — $24,600 over. No referral or Harrowgate approval is on the file; the adjuster’s note says the supervisor approved the full invoice.
Which claims should have been reported to us and weren’t?
Three are overdue. Linden Court — Gulfline’s $71,250 estimate on 2 Oct passed the $35,000 large-loss threshold; notice was due 6 Oct. Cypress Hollow — a suit filed 29 Sep was posted to the file on 2 Oct. Marigold Café — open six months on 3 Oct.
Where is Caldera’s leakage coming from this year?
Caldera’s estimate is $121,700, 2.97% of $4.1M paid — the highest share of the five. The biggest cause is deductibles not taken: 31 payments, $46,500. Today’s Saffron Table spoilage payment is another: $4,950 paid with no $1,000 deductible.
Is the Linden Court reserve adequate?
No. The indemnity reserve is $45,000 and $74,600 is already paid. Gulfline’s 2 Oct estimate of $71,250 has $9,050 not yet invoiced, so the file implies at least $83,650 incurred. The schedule wanted a review within ten business days of the estimate and never a reserve below paid.
13 screens from the working solution, on its sample data. Pick one to see it large.
Authority, clocks and thresholds are set per binder, from each claims administration agreement. Changes are drafts until a second person approves them.
| Setting | Default | Choose from |
|---|---|---|
| Indemnity authority per claim | $50,000 — Bramblecrest, Coastal Habitational Property | Set per binder: $35,000 to $75,000 across the six binders |
| Large-loss notice threshold | $35,000 | Set per binder: $25,000 to $50,000 |
| First contact | 1 business day from notice | Any number of business days |
| Initial reserve | 5 business days from notice | Any number of business days |
| Reserve review after new information | 10 business days | Any number of business days |
| Reserve tolerance | 15% against the latest estimate | Any percentage |
| Diary limit | 30 days without activity | Any number of days |
| Hold payments automatically | Never — a person places every hold | Off by policy |
Every figure is labelled: a target the solution is built to, an estimate, a typical published result, or a proven one.
“demo” = seen in the working solution, on its sample carrier, administrators and claims · “target” = the design goal, measured in the live solution · “estimated” = our estimate · “typical” = published figures (claims leakage issue briefs put leakage at 5–10% of claims paid; Insurance Thought Leadership cites 7–14%). Context: FCA, home and travel claims handling good and poor practice (2025); NAIC Managing General Agents Act (Model 225), as enacted (e.g. NC GS 58-34-2); Lloyd’s, Delegated Claims Administrators; LMA Delegated Claims Standards (LMA20-036). People, carriers, administrators, insureds and vendors named on this page are fictional — characters and sample data in the working solution.
Software that lets a carrier or managing agent oversee the claims its delegated administrators handle under their own authority. Delegated Claims Audit reads every file event a TPA posts — notes, reserve changes, payments, letters — as it lands and runs seven checks on it, instead of sampling files at an annual audit.
The authority checker sums paid and reserved indemnity and expense on the claim, compares the total with the authority schedule for that binder, and looks for a referral or carrier approval on the file. On the hero claim it found $74,600 paid against $50,000 of authority with no referral, the minute the check was cut.
Yes. The payment checker matches every invoice line against every prior payment on the claim, and checks the payee and the deductible. In the working solution it found a $6,200 structural drying line paid twice and a $1,000 deductible not taken on a spoilage payment, and the leakage estimator priced both.
The reportable-claim finder applies the triggers in each binder’s claims authority schedule — likely above the notice threshold, above authority, a coverage dispute, a suit, open more than six months. Several of these, such as a coverage dispute or a claim open more than six months, are also on the state MGA laws’ list of claims an administrator must report to the insurer. It starts the 2-business-day clock the day a trigger is met and drafts the notice.
No. Holding payments automatically is off by policy, and the agents have read-only access to the administrators’ systems. The claims manager places every hold, sends every request and notice, and accepts every leakage finding; authority changes need a second approver.
Every badge cites the file note and the rule it applied, and the same event always gets the same answer. Before a change runs, a check can be tested on last month’s events: in the working solution, September’s 36,904 events were compared with the 412 files the claims auditor reviewed — none missed, six flagged in error, all six referrals sent by email and attached late.
A feed from each administrator’s claims system, the monthly claims bordereaux, the claim files, your binders and claims authority schedules, policy forms and endorsements, and your vendor list and rate guidelines. In the working solution each TPA feed refreshes every 30 seconds.
The Agentic Solution Engine builds and deploys it from your requirements and documents — your binders, authority schedules, claims administration agreements and a sample of your administrators’ files — and it goes live once every quality gate has passed. We will walk you through it on your own TPAs’ files first.
Every bordereau in your layout on arrival, each rejected row with its reason.
1-min demoBinding Authority ComplianceBreaches flagged the day the risk is bound, not months later at audit.
1-min demoBinder Guidelines SearchFewer needless referrals, and every answer shows the clause that decides it.
1-min demoWe’ll run Delegated Claims Audit on a month of your own administrators’ file events.