Fraud Investigation Referral Criteria & Summary

You are identifying claims with potential fraud indicators.

PASTE THE FOLLOWING:
{{claim_facts_loss_type_reported_amount_cl}}
{{inconsistencies_or_red_flags_noted}}
{{claimant_credibility_assessment}}
{{evidence_contradicting_narrative}}

YOUR TASK:
1. Identify all fraud red flags
2. Rate fraud probability: low / low-moderate / moderate / high
3. If >20%, draft fraud referral memo with recommended steps
4. Identify what evidence would confirm/refute fraud
5. Determine interim handling: full reserve / reduced / suspended

OUTPUT FORMAT:
JSON object with: red_flags (array), fraud_probability_percent, referral_memo (if applicable), needed_evidence (array), interim_handling_decision

Be specific about red flags; avoid profiling.

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Why this works

Structured assessment enables early investigation of likely fraud.

Risks & review

Fraud investigation can antagonize innocent claimants and trigger bad-faith claims.