An insurance claim can involve policy information, medical records, treatment dates, payment acknowledgements and financial documents from several sources. When those records are incomplete or inconsistent, the claim may require a more detailed review before a decision is made.
Global Screenings provides insurance claim verification and SIU investigation support for insurers, employers and other authorized organizations. The review is based on the documents, records and questions included in the agreed scope.
Insurance Claim Verification
A claim verification review can help establish whether the information supplied is consistent with the available policy, treatment, employment and payment records.
The purpose is not to assume that a claimant has acted improperly. A difference may result from an administrative error, incomplete documentation, delayed reporting or information that requires further explanation.
What an Insurance Claim Review Can Include
Depending on the claim type and available records, the review may include:
- Insurance claim eligibility checks
- Claim status verification
- Insurance policy and coverage checks
- Medical statement verification
- Medical treatment record review
- Treatment and payment acknowledgement checks
- Medical insurance and financial record review
- Healthcare claim validation
- Workers’ compensation history
- Review of medical documents that appear inconsistent or require confirmation
Claim Eligibility and Policy Coverage
A claim may depend on whether the policy was active, the event falls within the stated coverage and the claimant meets the relevant eligibility requirements.
The review may compare:
- Policy details
- Coverage dates
- Claim dates
- Claimant information
- The type of treatment or loss reported
- Supporting documents provided with the claim
Global Screenings can report information identified within the agreed review. The insurer or responsible claims authority remains responsible for interpreting the policy and deciding whether the claim is covered.
Medical Statement and Treatment Verification
Medical statements and treatment records can be central to an injury or healthcare claim. The review may examine whether the documents are consistent with the claimant, medical provider, treatment dates and information stated in the claim.
Where included in the scope, verification may consider:
- The identity of the medical provider
- The dates of consultation or treatment
- The claimant details shown on the documents
- The treatment or examination described
- Payment or acknowledgement records connected with the treatment
- Whether the document can be confirmed through an available source
This is a document and information verification service. It does not replace a medical examination, provide a clinical diagnosis or determine the severity of an injury or illness.
Payment and Financial Record Review
Claim files may contain invoices, payment acknowledgements, insurance records and other financial information. These documents can be reviewed for consistency with the treatment, dates, provider and amount described in the claim.
A difference in an amount or date does not by itself prove wrongdoing. It may require clarification, supporting records or further investigation before a conclusion is reached.
Workers’ Compensation History
Where relevant and available, a claim review may include workers’ compensation history connected with the claimant or reported incident.
This information can be considered alongside employment records, injury dates, treatment documents and other details included in the current claim. More focused support is available through our Workers’ Compensation Claim Verification service.
Healthcare Claim Validation
A healthcare claim may involve treatment records, invoices, policy information and acknowledgements from medical providers. Validation can help determine whether the available documents and claim details are consistent with one another.
The review may identify:
- Missing supporting documents
- Conflicting treatment dates
- Differences in claimant information
- Unconfirmed medical providers
- Payment records that require clarification
- Documents that appear altered, incomplete or inconsistent
When a Claim Requires Further Investigation
Some matters cannot be resolved through document verification alone. If the available information raises additional questions, a broader investigation may be required.
Examples may include:
- Repeated or conflicting medical documents
- Unverifiable treatment providers
- Differences between policy dates and claim dates
- Inconsistent claimant or employment information
- Payment records that do not correspond with the treatment described
- Other material discrepancies within the claim file
Where a wider inquiry is required, the matter may also be considered through our Investigation Services.
Reporting the Findings
The completed report can identify information that was confirmed, information that could not be verified and any inconsistency requiring further consideration.
A claim should not be described as fraudulent solely because a record is incomplete or a discrepancy has been identified. The available evidence, explanation and wider claim circumstances should be considered before a decision is made.
Global Screenings provides verification and investigation findings from the agreed scope. Final decisions on claim eligibility, policy coverage, payment, medical necessity or fraud remain with the insurer, employer, claims administrator, legal adviser or other responsible authority.
