Understanding Claims Triage and Resource Allocation

A useful way to understand claims triage is to think about how an emergency room operates. When patients arrive, a triage nurse assesses each one. A broken arm gets routed one way; a possible cardiac event goes somewhere else. The goal is to match the level of care to the level of urgency so nothing critical gets delayed. Claims triage follows that same logic.  

Most carriers process hundreds, sometimes thousands, of new claims every week. And while some close within days with minimal involvement, others develop into complex, multi-year cases that require senior adjusters, clinical oversight, and investigative resources. Triage helps claims teams identify which is which, early enough to make a difference.  

What Claims Triage Does 

Claims triage is the evaluation and routing of incoming claims based on risk, severity, and potential cost exposure. It typically happens at intake and again at escalation points throughout the claim lifecycle as new information changes how the claim should be handled.  

The purpose is resource allocation. High-severity, complex claims require prompt attention from experienced professionals, whereas lower-complexity claims can move through standard workflows without consuming the same level of time and expertise. Triage is what separates the two.  

According to NCCI, lost-time claim frequency dropped 5% in 2024, while medical and indemnity severity both rose by 6%, and claims are taking longer to resolve. Fewer claims are coming in, but each one requires more time and resources.  

At the same time, industry workforce surveys show many insurers expect revenue growth, yet only about half plan to increase staff in the next 12 months. In other words, the workload is expanding. Team capacity largely is not.   

Those imbalances are where triage decisions matter most.  

What Gets Evaluated During Triage 

Triage draws from several data points at once. Policyholder information, type of loss, injury severity, location, and mechanism of injury all factor into the picture. Attorney involvement, prior claim history, patterns among treating providers, and comorbidities can add further context.  

Research from Risk & Insurance found that 58% of complex workers’ comp claims include at least one comorbidity, and comorbidities increase the likelihood of claim complexity by 33%. That kind of data changes how a claim should be handled from day one. 

Timing matters too. Rapid cost growth in the first 30 days is a signal worth paying attention to, and so is attorney involvement at first notice of loss. When certain employer groups, providers, or injury types have historically led to prolonged treatment or litigation, similar new claims get flagged earlier. Pattern recognition is a big part of what distinguishes effective triage from basic sorting.  

Where Manual Triage Falls Short  

For a long time, triage has been a judgment call. An adjuster reviews the file, applies their knowledge, and routes it accordingly. Experienced adjusters bring real value, but purely manual triage has certain limitations that compound at scale.  

Two adjusters can look at the same claim and route it differently. Regional practices vary, and high volume creates time pressure that leads to inconsistency. When decisions hinge on individual experience rather than consistent criteria, claims that need the most attention sometimes don’t get flagged until weeks into the lifecycle. And by then, costs have already started to climb.   

The Shift Toward Data-Driven Triage 

Carriers are gradually moving away from purely manual, rule-based routing toward forms of automation. Industry estimates show that insurance carriers report processing costs 30-50% lower when workflows incorporate automated decision support compared to manual processes.  

Predictive analytics and machine learning models can analyze patterns across large volumes of claims and flag indicators such as injury type and employer history to identify high-cost claims early. Modern triage approaches help adjusters understand a claim’s probable path based on how similar claims have developed and been resolved.  

Early intervention matters, as the window for effective action closes quickly. A complex claim identified at day three looks very different at resolution than the same claim identified at week six.  

What Better Triage Looks Like 

Consider two workers’ comp claims that come in on the same day. Both involve lower back injuries, and the initial medical reports look similar.  

But the underlying data tells a different story. The first claimant has no prior injury history, works for an employer with a strong return-to-work program, and the treating physician documented a conservative care plan. The second claimant, on the other hand, has multiple prior claims, retained an attorney at first notice of loss, and the medical notes reference a possible surgical recommendation.  

The first claim routes to standard handling and closes six weeks later with minimal cost. The second claim goes to a senior adjuster experienced in litigated cases and triggers early clinical review. That claim stays open longer, but early intervention can prevent the cost escalation that typically happens when complex claims sit in a standard queue.  

The difference comes down to the triage decision made in the first 24-48 hours.  

Where Triage is Headed 

More carriers are investing in decision support tools that bring consistency to triage, particularly at intake, where early decisions have the most downstream impact. Triage is shifting from static rules to more guided, data-informed decision-making.  

Tools like Pathfinder are part of that shift, helping claims teams allocate investigative and clinical resources based on actual risk indicators and historical data rather than broad assumptions.  

Triage rarely gets the attention it deserves, but in many ways it sets the tone for everything that follows. The decisions made early in a claim’s life have a way of compounding over time, and carriers that treat triage as a strategic function as opposed to an administrative step tend to see that reflected in their outcomes.  

As claim complexity continues to grow, the quality of those early decisions matters more than ever.  

Check out our sources:

Databricks. (2025, November 28). Navigating the Impact of AI in Insurance: Opportunities and Challenges. https://www.databricks.com/blog/navigating-impact-ai-insurance-opportunities-and-challenges  

Laman, A. (2025, August 18). Carrier Revenue Growth Expected to Outpace Hiring in Next Year. Insurance Journal. https://www.insurancejournal.com/news/national/2025/08/18/835619.htm 

Risk & Insurance. (2025, November 24). The Current State of Complex Claims in Workers’ Compensation: Understanding the Drivers of Rising Costs and Duration. https://riskandinsurance.com/the-current-state-of-complex-claims-in-workers-compensation-understanding-the-drivers-of-rising-costs-and-duration/  

Sullivan, S., et al. (2025, October 8). 2025 in Sight, 2024 in Review: The Latest Results for Workers’ Compensation. NCCI.  

https://www.ncci.com/Articles/Pages/Insights-2025-in-Sight-2024-in-Review.aspx