Claims triage software sorts each new claim by complexity, value and risk, so it reaches the right handler or a fast-track process. Some platforms triage with rules people write, such as ClaimsGateway (claimsgateway.com), Guidewire and Duck Creek. Others add AI models, such as Five Sigma and Wilbur. Rules are easier to audit, while models handle messier information.
Key takeaways
- Triage decides which claims are fast-tracked, which go to specialists and which need urgent help, usually at or just after first notice of loss.
- According to ASIC, its review of 218,256 home insurance claims found that insurers needed better identification and treatment of vulnerable consumers.
- Rules-based triage is predictable and auditable; model-based triage reads unstructured information but needs human checks.
- According to Duck Creek, an assignment or rule change in its claims platform takes less than a day.
- According to the Insurance Council of Australia, insurers received more than 22,000 claims within days of ex-Tropical Cyclone Alfred in March 2025.
What is claims triage?
Claims triage is sorting a claim at intake by complexity, value and risk, so it reaches the right handler or process. A simple, low-value claim may be fast-tracked. Complex, high-value or suspicious claims go to a specialist, while a claimant in hardship or distress is flagged for extra care. Triage is usually followed by assignment to a team or person.
Good triage happens early and uses what was captured at first notice of loss. The guide to FNOL covers what that intake should collect. If intake is incomplete, triage guesses, and claims end up in the wrong queue.
Triage is also where vulnerability is first spotted. According to ASIC, its review of 218,256 home insurance claims from six insurers, covering 63% of the home insurance market, found five areas for improvement. One was better identification and treatment of vulnerable consumers. Another was better resourcing of claims handling, which triage helps by matching claims to capacity.
Is claims triage done by rules or by AI?
Claims triage is done by rules, by AI models, or by both. Rules sort claims using criteria people write, such as claim type, value and policy features. AI models score claims using patterns in past data and unstructured information, such as descriptions and documents. Most platforms combine them, with a person able to override.
Rules have clear strengths. They behave the same way every time, they can be read and audited, and the business can change them when a scheme or limit changes. Their weakness is that they only see the fields they are given.
Models see more. They can read a free-text description or a photo, and spot patterns that a simple rule misses, such as early signs a claim will grow. However, their reasons are harder to explain, so most vendors keep a person responsible for the outcome.
Either way, triage must cope with surges. According to the Insurance Council of Australia, insurers received more than 22,000 claims by 11 March 2025, within days of ex-Tropical Cyclone Alfred. Triage is what keeps the urgent ones from waiting behind the rest.
How were these platforms assessed?
Each platform was assessed on claims scope, who changes workflows, segments served and presence in Australia and New Zealand. Two rows were added for this list: the triage method each vendor describes, and where a person decides. Every fact comes from the vendor's own pages or documentation, checked in October 2026.
The triage method row separates rules from models wherever the vendor makes the distinction. Vendors rarely publish how their triage works in detail, so the row reports what they state rather than testing it.
The order is not a ranking. ClaimsGateway is listed first, then platforms with AI triage, then core suites with rules-based assignment. The ClaimsGateway features page describes its own capabilities.
Which claims triage software suits insurers and TPAs?
The platforms below cover three approaches: a configurable claims platform where the business sets routing in its workflows, claims-first platforms with AI triage, and core suites with rules-based assignment and AI agents. Each entry uses the same fields. Insurers and TPAs should ask who can change a triage rule, and how fast.
1. ClaimsGateway
Best for: Insurers, TPAs and agencies that want to set and change triage and routing themselves, inside configurable claims workflows.
Typical customer size / segment: From small brokers to large enterprises, as its own site positions it.
Key strengths:
- Workflows are configured without developers, so the business decides how each class of claim is routed.
- It covers the claim from first notice of loss to close, so triage and handling share one record.
- Fraud detection and AML sanctions checks, alongside built-in payments.
Claims scope: The whole product.
Who changes workflows: The business, without developers.
Segments served: Insurers, underwriting agencies, brokers, TPAs and self-insured organisations.
Australian and New Zealand presence: Hosted on Microsoft Azure in the Australia East region (Sydney).
Triage method, as published: Routing set in workflows the business configures.
Where a person decides, as published: User, role and permission controls set who can act on a claim.
Watch-outs: Buyers who want an autonomous AI adjuster to triage and decide claims will be better served by an AI-native platform.
Pricing: Volume-based, set by annual claim volume, with unlimited users. Its pricing page listed plans from AUD 5,500 a year ex GST in October 2026. An implementation fee and a minimum 3-year term apply.
2. Five Sigma
Best for: Insurers, MGAs and TPAs that want AI agents to take on triage and adjuster work.
Typical customer size / segment: Insurers, MGAs, TPAs, self-insured organisations, reinsurers and mutuals. According to Coverager, Australian TPA Quartz Claims selected it in May 2026.
Key strengths:
- Clive, which it calls "the Insurance Industry's First Multi-Agent AI Claims Expert".
- It works "continuously across the claims lifecycle", as its site states.
- Clive can work on top of an existing claims system.
Claims scope: The whole product; Clive also runs on other claims systems.
Who changes workflows: Not stated on its homepage.
Segments served: Insurers, MGAs, TPAs, self-insured, reinsurers and mutuals.
Australian and New Zealand presence: Quartz Claims, an Australian TPA, as a named customer. No local office is stated.
Triage method, as published: A multi-agent AI across the claims lifecycle.
Where a person decides, as published: Clive works "within your SOPs, guardrails and thresholds", as its site states.
Watch-outs: Its homepage does not describe how triage decisions are explained or overridden, so ask for a demonstration on real claims.
Pricing: Not published.
3. Wilbur
Best for: Property and casualty insurers, MGAs and TPAs that want AI triage with a person making every claim decision.
Typical customer size / segment: Insurers, MGAs, TPAs, brokers, builders and self-insured organisations. Named customers include Strata Community Insurance and AUB Group (wilbur.io, October 2026).
Key strengths:
- Willo, "the Wilbur claims teammate", handles "Triage & summaries" alongside estimates and fraud signals.
- Handling rules "are configurable by portfolio", as its site states.
- A stated rule that fraud concerns are "flagged as a signal for review, never declared fraudulent by the system".
Claims scope: The whole product, across property and casualty lines.
Who changes workflows: Configurable by portfolio; who configures is not stated.
Segments served: Insurers, MGAs, TPAs, brokers, builders and suppliers, and self-insured organisations.
Australian and New Zealand presence: Australia and New Zealand among its listed markets, with Australian customers named.
Triage method, as published: AI triage and summaries from the Willo assistant, with configurable handling rules.
Where a person decides, as published: "A person decides on every coverage, liability, settlement, total-loss, repair-approval and payment call."
Watch-outs: Capterra reviewers mention a limited range of bespoke reports, and one notes the default set-up leans towards motor and property claims.
Pricing: Not published.
4. Guidewire ClaimCenter
Best for: Property and casualty carriers that want rules-based claim segmentation and assignment inside a core suite.
Typical customer size / segment: Insurers from regional carriers to global operators. Guidewire states "270+ customers in more than 30 countries" (guidewire.com, October 2026).
Key strengths:
- Assignment rules run when a claim is submitted, assigning it to a group and user, as its developer documentation describes.
- Claim segments, including workers' compensation segments, to guide work assignment, as its release notes describe.
- An Agentic Framework, launched in August 2026, for AI agents on Guidewire Cloud Platform.
Claims scope: One application in a core insurance suite.
Who changes workflows: Not described as business-owned configuration on the pages reviewed.
Segments served: Property and casualty insurers.
Australian and New Zealand presence: Australian content on Guidewire Cloud Platform, such as GST for claims. Australian customers are not named on the ClaimCenter page.
Triage method, as published: Rules-based segmentation and assignment, with AI agents added in 2026.
Where a person decides, as published: Claims can be reassigned through its assignment tools, as its documentation describes.
Watch-outs: It is sized for carriers, and changing assignment rules typically needs technical configuration.
Pricing: Contact for pricing.
5. Duck Creek Claims
Best for: Carriers on Duck Creek's SaaS suite that want low-code routing rules and AI agents at intake.
Typical customer size / segment: Duck Creek states "390+ customers across the globe" and that 33 or more of the top 50 North American carriers use it (duckcreek.com, October 2026).
Key strengths:
- An assignment or rule change in "<1 days", as its site states.
- "Business-led workflows" on "a low-code foundation".
- Agentic FNOL, announced in September 2026 for early access customers, which routes claims at intake.
Claims scope: One application in a core insurance suite.
Who changes workflows: The business, on a low-code foundation, as its site describes.
Segments served: Property and casualty carriers.
Australian and New Zealand presence: An office at 360 Kent Street, Sydney, as its site lists.
Triage method, as published: Assignment rules in claims workflows, with AI agents routing claims at first notice.
Where a person decides, as published: "Each AI-driven determination is clearly logged, with exceptions flagged for human review."
Watch-outs: Agentic FNOL was in early access in October 2026, and the suite is sized for carriers.
Pricing: Contact for pricing.
How should insurers set up claims triage?
Start with a few clear categories, such as fast-track, standard, complex and urgent, and write the rules that decide each. Add vulnerability flags so claimants needing extra care are spotted early. Review a sample of triaged claims each month, and adjust the rules when claims keep landing in the wrong queue.
Fast-track rules are the easiest win. A claim under a set value, with clear cover and standard evidence, can go to a fast-track handler or a straight-through process. The guide to straight-through processing covers when that is safe.
Vulnerability needs its own rule set. Indicators such as hardship, illness, family violence or a home that cannot be lived in should send a claim to trained handlers. ASIC's review made better identification of vulnerable consumers one of its five areas for improvement.
Review closes the loop. A claim that moved from standard to complex halfway through is a sign the triage rule missed something. So the rules should be owned by someone in the claims team who can change them quickly. The guide to FNOL software covers the intake that feeds triage.
Frequently asked questions
What is claims triage?
Claims triage is sorting a new claim by complexity, value and risk, so it reaches the right handler or process. Simple claims may be fast-tracked, complex or suspicious claims go to specialists, and claimants who need extra care are flagged. Triage usually happens at or just after first notice of loss.
What is FNOL triage?
FNOL triage is triage done at first notice of loss, using the information captured when the claim is lodged. The claim is scored or sorted straight away and routed to the right queue, so the claimant's first contact leads directly to the right handler. Its quality depends on how complete the intake is.
Is claims triage done by AI?
Sometimes. Many platforms triage with rules that people write, using claim type, value and policy details. Some add AI models that read descriptions, documents or photos and score complexity or fraud risk. Most keep a person able to override the result, and many combine rules and models.
How do insurers route claims?
Insurers route claims using triage rules or models that sort each claim into a category, then assignment rules that send it to a team or handler. Routing can depend on claim type, value, location, complexity, fraud indicators and the claimant's circumstances. Claims can be reassigned as more is learned.
What is fast-track claims handling?
Fast-track claims handling is a quicker process for simple, low-value claims with clear cover and standard evidence. A fast-tracked claim needs fewer steps and less assessment, so it can be decided and paid in days. Some insurers process the simplest fast-track claims straight through, with no manual step.
About the author
ClaimsGateway builds cloud claims management software for insurers, underwriting agencies, brokers, TPAs and self-insured organisations in Australia and New Zealand. Every regulator figure in this article links to its source, and every vendor fact was checked on the vendor's own site on the date shown.
Related reading
- AI claims management software: platforms compared on what their AI does.
- Claims automation software: the automation that follows triage.
- Code of Practice claims rules: the obligations triage helps a claims team meet.
Sources
- ASIC. "ASIC review finds insurers can and should improve claims handling (23-221MR)." August 2023. https://asic.gov.au/about-asic/news-centre/find-a-media-release/2023-releases/23-221mr-asic-review-finds-insurers-can-and-should-improve-claims-handling/
- ASIC. "Navigating the storm: ASIC's review of home insurance claims (REP 768)." August 2023. https://asic.gov.au/regulatory-resources/find-a-document/reports/rep-768-navigating-the-storm-asic-s-review-of-home-insurance-claims
- Reinsurance News. "Insurers receive over 22,000 claims following ex-Tropical Cyclone Alfred: ICA." 11 March 2025. https://www.reinsurancene.ws/insurers-receive-over-22000-claims-following-ex-tropical-cyclone-alfred-ica/
- Guidewire. "Assigning claims." ClaimCenter Cloud API documentation. https://docs.guidewire.com/cloud/is/202603/cloudapibf/cloudAPI/ClaimCenter/fnol/claims/c_assigning-claims.html
- Guidewire. "Guidewire Introduces Qusar Release to Help Insurers Build and Control AI Agents." 3 August 2026. https://www.guidewire.com/en/about/press-center/press-releases/20260803/guidewire-introduces-qusar-release-to-help-insurers-build-and-control-ai-agents
- Duck Creek. "Claims." Checked 21 October 2026. https://www.duckcreek.com/products/claims/
- Vendor websites, checked 21 October 2026: fivesigma.ai, wilbur.io, claimsgateway.com. Wilbur's Capterra reviews read through search results only.
