Insurance QA Scorecard: Criteria and Free Templates for Claims, Servicing, Sales, and Medicare Calls

Would your call center be able to manage the situation in such a way that no compliance issue will result in a costly mistake?

Any mistake made in non-disclosure, incorrect insurance coverage forms, or verification would be a costly one for the company.

Insurance QA scorecards will assist you and your team in testing claims, services, sales, and Medicare calls according to the required compliance standards.

Here you will find all QA criteria, weights, auto-fails, and some free insurance QA scorecard templates.

What an insurance QA scorecard needs that a generic one does not

Most contact centers start with a generic customer service qa scorecard. Those forms score greetings, manners, and handle time. 

Our guide on call center agent scorecards covers the basics of weights and scoring.

Insurance asks for more. A strong insurance QA scorecard covers four areas that generic forms skip:

• Regulatory disclosures: In two-party consent states, agents must state the recording notice. They must also give health plan disclaimers before talking about coverage.
• Coverage accuracy: The deductibles, endorsements, and limits need to comply with the system. There will be no payment until the case is reviewed by someone.
• Steps to be considered in claim/policy: The client needs to be informed about the time bar, proof of loss, and the letter of reservation of rights.
• Core system documents: Whatever the agent says should be recorded on Guidewire, Duck Creek, or Applied Epic.

Scorecard structure: sections, weights, and auto-fails

• A well-built insurance QA scorecard scores each call out of 100 points. The pass mark is 85%. 
• Auto-fail rules matter because a happy customer shouldn’t hide a serious violation. 
• If an agent skips a required disclosure or shares data with an unverified caller, the insurance QA scorecard zeros the call right away.

Recommended weight split by call type

Every call type has its own goal. FNOL calls need accuracy and warmth. Servicing calls lean on identity checks. 

Here’s the weight split for an insurance QA scorecard:

Auto-fail items and the rule behind each

Automated failure is either a violation or a potential one. This guarantees that by ensuring such controls are present in your insurance QA scorecard, your company will not have any audits or legal issues.

Template 1: FNOL and new claim calls

• On an FNOL call, the agent has two jobs. 
• Get the facts of the loss, and calm a policyholder who just had a bad day. 
• Intake agents should never decide liability or promise a settlement. That’s the adjuster’s call.

Our breakdown of claims quality assurance shows why you should check spoken statements against the claim file. It stops costly errors. 

Use these criteria in your insurance QA scorecard for first notice calls:

Template 2: Claims status and follow-up calls

• People who call for claim updates are often confused. Timelines slip. 
• Repair approvals sit in a queue. 
• An insurance QA scorecard for status calls makes sure agents give accurate reserve and payment details. 
• This should cover how to reach the claims adjuster, which forms must be completed, and the full escalation process. 

Template 3: Policy servicing calls

• Service Calls are common activities. 
• The problems that may come up include those of billing, new drivers, address changes, and endorsements. 
• The Service Insurance QA Scorecard is used for validating identity, change, date, and document evidence.

Template 4: Sales and renewal calls

• The sales and renewal calls require proper suitability tests and binding disclosures.
• Include these tests in your insurance QA scorecard. 
• The agents will be in a position to understand the needs of the client, carry out the suitability test, inform on the major exclusions, and get the binding agreement.

Template 5: Medicare Advantage and Part D sales calls (CY2027)

• Medicare sales are heavily regulated. 
• In regard to marketing for Contract Year 2027, the agent needs to read the TPMO disclaimer out loud prior to any discussion about benefits. 
• CMS further requires you to retain the call recordings for six years.

Need the full rule text and exact wording? 

Read our CMS call recording requirements. Use this health insurance QA scorecard for Medicare sales calls:

Which criteria AI can score reliably, and which need a human

Speech analytics is great at rule-based checks. Nuance becomes another matter. The automation process in your QA insurance scorecard frees your QA department to coach where nuance comes into play.

Our guide on contact center optimization explains how AI agents speed up quality management and back up human auditors. 

The table shows how to split scoring duties across an insurance QA scorecard:

Calibrating insurance QA scores across teams

• Calibration will make sure that there is standardization during the scoring process for any supervisor, quality analysts, or compliance officers.
• Without it, raters will vary. Two people score the same call and land far apart. 
• A well-governed insurance QA scorecard depends on monthly calibration sessions.
• Use the frameworks in our call center audit guide to plan them. Pick five to ten anchor calls. 
• Mix in simple endorsements, upset claimants, and complex claims intake. Each reviewer scores every call alone with the insurance QA scorecard. 
• Then the group meets, compares findings, and calculates agreement using Fleiss’ Kappa statistic. Ideally, achieve at least a 0.80 value.
• Scores don’t match? Fix the wording in the insurance QA scorecard. 
• Don’t force subjective changes. Keep an agent dispute process, too. 
• Agents may contest docked points within five days by providing call timestamp details.

From 2% sampling to 100% coverage: rollout in four steps

Examining only 1% to 3% of calls creates huge blind spots. To increase your insurance QA scorecard to 100% of calls, you will need four things:

• Step 1: Implement Auto-Fail Surveillance. Utilize speech analytics to monitor compliance in relation to required checks for each and every call. Identify any lack of recording notice or TPMO disclaimer.
• Step 2: Automate process accuracy audit. Use speech recognition to check caller verification, claim number validation, and changes in records.
• Step 3: Behaviour analytics implementation. Sentiment analysis, hold time, and dead air analysis will provide an understanding of the quality of the services provided.
• Step 4: Close-loop coaching. Tie the scorecard findings to the dashboard of the agents. Coaching should be done if performance lags.

Carriers and TPAs speed this up with Thunai for Amazon Connect. Some pair it with Webex Contact Center, as shown in our guide to AI quality assurance in Webex. 

Enterprise contact centers rate Thunai 4.8/5. It has 100% accuracy in voice and chat interactions with the help of custom scorecards and standard operating procedures. 

Call logging, identification of escalations and compliance issues, and CRM logging are performed.

Utilize your insurance QA scorecard every time and allow Thunai to eliminate your audit blind spots. Managers get objective data to coach agents.

Are you ready to enhance your company’s compliance and remove QA blind spots? Schedule your Thunai demo now and use AI scorecards for insurance call automation.

FAQs

What should an insurance QA scorecard include?

The insurance QA scorecard should consider ID verification, notice documentation, coverage accuracy, empathy, and core system notes. Every legal mandate must be a zero-tolerance point on the QA scorecard.

What is the number of points that a call center QA scorecard should have?

Aim for 8 to 12. Twenty or more tires out reviewers and weakens coaching talks. Group criteria under clear sections like compliance, accuracy, and customer experience.

What is a good QA score in an insurance call center?

An 85% score is the standard pass mark. Strong teams average 90% to 94%. Report compliance scores on their own so soft skills never hide fatal legal errors.

Should Medicare sales calls use a separate QA form?

Yes. Medicare calls need their own insurance QA scorecard built on CMS rules. Standard servicing forms lack checks for Scope of Appointment, TPMO disclaimer timing, and six-year recording retention.

Can AI score insurance calls accurately?

For script adherence, authentication steps, and required disclosures, yes. For hard cases like unclear policy language or severe claims losses, the tools flag the call for human review.