AdjudiCLAIMS is an AI-powered claims management tool for California Workers' Compensation claims examiners. Adjuster in the loop, always. The product IS the training program.
517
UPL test fixtures (126 RED + 126 GREEN + 62 YELLOW + 203 output variations)
46
Prohibited output patterns blocked by AI validator
69
SOC 2 compliance tests (CC6/CC7/CC8)
7-year
Immutable audit log retention
What AdjudiCLAIMS Is
CA WC claims examiners face 20+ mandatory regulatory workflows, 5 simultaneous deadline clocks, and the constant risk of bad faith exposure from procedural errors. AdjudiCLAIMS doesn't just help examiners comply — it teaches them why each step matters.
Deadline calculations, benefit arithmetic, statutory citations, document extraction. Every factual output grounded in statute and regulation. No legal analysis — pure information.
Comparable claims data, reserve benchmarks, industry statistics. Delivered with mandatory disclaimer: consult defense counsel for legal analysis. Statistical context, not legal conclusions.
Questions requiring legal analysis are blocked — not answered with disclaimers. Attorney referral. Cal. Bus. & Prof. Code § 6125 compliance is non-negotiable. 126 RED zone queries: 100% blocked.
Platform Features
Built to address the full regulatory lifecycle of a California workers' compensation claim — from first notice of injury through closure. Every feature cites its statutory authority.
Five simultaneous deadline clocks from Day 0: 15-day acknowledgment, 14-day first TD payment, 40-day accept/deny, 90-day presumption, 30-day delay notification cycle. Every deadline cites its statute.
AWE computation, 2/3 statutory rate, minimum/maximum bounds for the injury date year. Calculated from wage records with step-by-step citation to LC 4653. Every calculation auditable — no black box arithmetic.
Diagnoses, WPI ratings, work restrictions, treatment history extracted from QME/AME reports and medical records with citations to specific pages. 5–10 minutes vs. 2–4 hours manual review.
Treatment requests cross-referenced against 2024 MTUS guidelines for utilization review. Evidence-based medicine basis cited. UR decisions grounded in applicable ACOEM standards — not examiner judgment alone.
Step-by-step guidance for every major claims decision: intake, coverage determination, TD initiation, denial issuance, UR authorization, QME/AME process, and 14 more. Every step cites its statutory authority.
Three-point contact protocol status, outstanding documentation checklist, SIU referral triggers. The investigation record is the audit record — every attempt documented, every gap identified.
UPL Compliance Architecture
Unauthorized Practice of Law under Cal. Bus. & Prof. Code § 6125 is not a marketing compliance checkbox. It is a hard legal requirement governing every AI output to a claims examiner.
Layer 1: Query Classifier
Pre-chat zone classification. Every query classified GREEN/YELLOW/RED before the AI responds. RED zone queries never reach the AI — they are blocked at the classifier.
Layer 2: System Prompt
Role-specific prompt architecture enforces zone boundaries. Claims examiner prompts are calibrated to GREEN zone output only, with YELLOW statistical context and mandatory disclaimers.
Layer 3: Output Validator
46 prohibited output patterns detected post-generation. 203 response variations tested — 100% caught. Legal conclusions that slip past the prompt are caught before delivery.
UPL Test Suite Results
126 RED zone queries
Zero legal advice delivered
100% blocked
126 GREEN zone queries
Factual guidance never blocked
0% false positives
62 YELLOW zone queries
Mandatory attorney referral language
100% include disclaimer
203 output variations
46 prohibited patterns detected
100% caught
Adjuster in the Loop, Always
AdjudiCLAIMS is not a claims automation system. It is a claims information system. Every coverage determination, every benefit decision, every denial is made by a licensed claims professional who has reviewed the AI-surfaced evidence and exercises independent judgment.