AdjudiCLAIMS guides claims examiners through every regulatory workflow with step-by-step instructions and statutory citations. The workflow is the training — every step explains why it matters.
Workflow names, statutory authority, UPL zones, step counts, and estimated times are shown. Step-by-step details are available inside the platform to licensed clients only.
All 20 Workflows
From first notice of injury through closure — every major regulatory decision has a guided workflow with statutory citations at every step.
Regulatory procedures required within 48 hours of receiving a workers' compensation claim notice. All regulatory clocks start on Day 0 — acknowledgment, TD payment, accept/deny, and the 90-day presumption.
Statutory Authority
10 CCR 2695.5(b); LC 5401; 8 CCR 10101; 8 CCR 10109
Industry-standard first investigative step: contact the injured worker, the employer, and the treating physician. Every attempt documented. Must begin immediately upon receipt of proof of claim.
Statutory Authority
10 CCR 2695.5(e); 8 CCR 10109; Ins. Code 790.03(h)(3)
Formal decision on compensability within 40 calendar days of proof of claim. Factual investigation is GREEN zone. Claims involving complex legal issues route to YELLOW — defense counsel consultation required before issuance.
Statutory Authority
Ins. Code 790.03(h)(5); 10 CCR 2695.7(b); LC 5402(b)
Temporary Disability wage replacement calculation and payment. AWE computation, 2/3 rate, statutory min/max. First payment due within 14 days of employer knowledge. Every calculation cites its statute. Entirely GREEN zone.
Statutory Authority
LC 4650; LC 4653; LC 4654
Formal issuance of a written claim denial. Requires completed investigation, specific factual basis, and statutory authority. Non-routine denials require defense counsel review. YELLOW zone — the denial decision may involve legal analysis.
Statutory Authority
10 CCR 2695.7(h); Ins. Code 790.03(h)(14); LC 5402(b)
Utilization review for treatment requests. Cross-references treatment against 2024 MTUS guidelines. Evidence-based medicine basis cited for every decision. Prospective, concurrent, and retrospective UR covered.
Statutory Authority
LC 4610; 8 CCR 9792.6 et seq.; MTUS (2024)
Qualified Medical Evaluator and Agreed Medical Evaluator process from panel request through report receipt. Statutory deadlines tracked. Panel assignment, scheduling, and report analysis steps covered.
Statutory Authority
LC 4060–4062; 8 CCR 30-38
Initial and periodic reserve review across four categories: indemnity, medical, ALAE, and liens. Adequate reserves are a prerequisite to good faith settlement. Must be completed within 48 hours of claim receipt.
Statutory Authority
Ins. Code 790.03(h)(6); carrier financial reporting
Structured decision process for determining when defense counsel referral is required. Legal complexity triggers: disputed causation, cumulative trauma, apportionment, multiple employers, attorney representation.
Statutory Authority
Cal. Bus. & Prof. Code § 6125; carrier litigation guidelines
Required written notification when a coverage determination cannot be made within 40 days. Must specify outstanding information and expected timeline. New delay letter every 30 days. 90-day presumption is absolute backstop.
Statutory Authority
10 CCR 2695.7(c); LC 5402(b)
Required employer notification within 15 days of each indemnity claim. Initiates wage record collection, employer date-of-knowledge determination, and modified duty assessment.
Statutory Authority
LC 3761; 10 CCR 2695.5(b)
Structured response protocol for California Department of Insurance audit requests. Documentation assembly, regulatory gap identification, and response preparation. The claim log is the audit record.
Statutory Authority
Ins. Code 1858; 10 CCR 2695 et seq.
Medical provider lien identification, evaluation, and resolution. EDD, Medicare, and third-party lien coordination. Lien filing requirements and statute of limitations tracked per statutory authority.
Statutory Authority
LC 4903; 8 CCR 10770 et seq.
Modified duty offer coordination, physician restriction compliance verification, and TD termination documentation. Correct termination requires documented valid basis — not assumption.
Statutory Authority
LC 4658; LC 4660; 8 CCR 10116
Structured claim closure checklist: final benefit payments, lien resolution, reserve run-off, documentation completion, and audit readiness confirmation. Every closure leaves a complete claim record.
Statutory Authority
LC 5500.5; 8 CCR 10109
Structured response to fraud indicators: SIU referral triggers, investigation continuance, and documentation requirements. Investigation must continue on the standard regulatory timeline while SIU evaluates.
Statutory Authority
Ins. Code 1871.7; 8 CCR 10109
Third-party liability identification and subrogation referral. Employer negligence, product liability, and motor vehicle third-party scenarios. Statute of limitations for subrogation actions tracked from injury date.
Statutory Authority
LC 3852; LC 3853; LC 3858
Specific handling requirements for cumulative trauma (CT) claims where the date of injury is determined by the last injurious exposure rule. Employer liability allocation and investigation requirements.
Statutory Authority
LC 5412; LC 5502; 8 CCR 10109
Death benefit processing for fatality claims: dependent identification, benefit calculation, burial expense, and survivor notification. Requires defense counsel coordination for dependency disputes.
Statutory Authority
LC 4700–4707; 8 CCR 10109
Mandatory 10% self-imposed penalty calculation for late TD payments. The penalty attaches automatically — the examiner must identify and apply it without waiting for a claim. Calculation cites LC 4650(c).
Statutory Authority
LC 4650(c); LC 5814
UPL Zone Distribution
18 of 20 workflows are entirely GREEN zone (factual, procedural, statutory). 2 workflows are YELLOW because the decision itself involves legal analysis that requires defense counsel. Zero workflows involve RED zone legal conclusions.
18
Factual + procedural guidance
2
Defense counsel required for determination
0
No legal conclusions delivered