AdjudiCLAIMS guides claims examiners through every phase of the CA WC claim lifecycle. The examiner makes every decision — the AI provides the factual information, statutory citations, and procedural guidance needed to make it correctly.
The Claim Lifecycle
A new claim arrives. AdjudiCLAIMS logs the receipt date, creates the claim file, and immediately activates all five regulatory deadline clocks: acknowledgment (15 days), first TD payment (14 days from employer knowledge), accept/deny (40 days), 90-day presumption, and delay notification cycle (30 days). Every clock cites its statute.
Upload medical records, QME/AME reports, DWC forms, and correspondence. AI provides 99%+ OCR accuracy on scanned documents and extracts diagnoses, WPI ratings, work restrictions, treatment history, and causation opinions — with citations to specific pages. 5–10 minutes vs. 2–4 hours manual review.
Guided workflow for contacting the injured worker, employer, and treating physician. Every contact attempt — successful or not — logged contemporaneously. Employer date of knowledge captured for correct deadline calculation. Investigation completeness assessed before coverage determination.
Factual AOE/COE assessment guided by the Coverage Determination workflow. Legal complexity triggers identified (disputed causation, cumulative trauma, apportionment) and routed to YELLOW zone — defense counsel consultation flagged before determination. Accept, delay, or deny with documented factual basis.
AWE computed from 52-week wage records. TD rate calculated at 2/3 of AWE, bounded by injury-year statutory min/max. First payment issued within 14 days of employer knowledge — not claim acceptance. Recurring biweekly schedule established. 10% self-imposed penalty calculator for any late payment.
Treatment requests matched against 2024 MTUS guidelines. Evidence-based medicine basis cited for every UR decision. QME/AME process managed from panel request through report receipt. Medical billing overview provides aggregate financial picture.
Every action logged to the 7-year immutable audit record. Supervisor compliance dashboard shows deadline status across the entire portfolio. DOI audit response workflow organizes documentation. The claim log is the audit record — every step documented.
Structured closure checklist: final benefit payments verified, all liens resolved, reserves run-off confirmed, documentation complete, audit readiness confirmed. Every closure leaves a complete claim record that survives a DOI audit.
Built for the Industry
AdjudiCLAIMS is purpose-built for California claims professionals — not adapted from a generic claims platform.
CA WC Regulatory Coverage
34 regulatory sections, all major deadlines, statutory citations on every screen.
HIPAA-Grade Security
BAA available. Zero-trust infrastructure. Immutable audit trail. 7-year retention.
Human in the Loop
AI provides information. The examiner makes every decision. No automation without consent.