Eligibility Verification and Auditing

Description and Importance

Verifies claims against settlement criteria (e.g., injury thresholds, exposure periods) to approve/deny. Audits prevent fraud; essential for court approval. 

Step-by-Step Process

Criteria Mapping: Review agreement matrix (e.g., points for age, injury severity). Build checklists or AI rules. 

Document Review: Cross-reference submissions (e.g., match exposure dates to records). Use tools for authenticity (e.g., metadata checks for forgeries). 

Auditing Subset: Randomly select 10–20% for deep dives (e.g., verify employment for asbestos exposure). Request third-party confirmations if needed. 

Decision Making: Approve/deny with reasoned explanations. Handle appeals by re-reviewing new evidence. 

Compliance Reporting: Log all for court; flag systemic issues (e.g., high denial rates in one region). 



Best practices: Independent auditors for objectivity; AI for initial pass (80% accuracy).