67 case types. Every one runs on a published rulebook and a named referee.
We screen a case type on 3 tests before we build for it: the work is document-driven, a named rulebook defines the correct output, and a named referee grades it on a known clock. These 67 pass, each with its own page naming that rulebook and referee outright, so you can check the standard before you send a file.
SSA disability — ALJ hearing prep, CDRs, DDS →
Rulebook: 20 CFR Pt 404 Subpt P App 1 (Blue Book Listings) + App 2 (Medical-Vocational Grids).
Referee: ALJ → Appeals Council → US District Court, where the substantial-evidence standard means a decision failing to address material evidence gets remanded.
SSA consultative examination (CE) vendor market →
Rulebook: 20 CFR §404.1519 through §404.1519t and §416.919 — the rules governing when a consultative examination is purchased, who may perform it, and what the report must contain.
Referee: The state Disability Determination Services examiner, who returns reports that fail the §404.1519n content requirements.
VA C&P exam contractors (MDE program) →
Rulebook: 38 CFR Part 4 Schedule for Rating Disabilities (each diagnostic code has explicit criteria); 38 CFR §3.303/3.304/3.307/3.309; §4.2 inadequate-exam standard.
Referee: MDEO's 10-question Quality Criteria Checklist, sampled quarterly; contract SLAs impose financial penalties for error rates above threshold.
Camp Lejeune Justice Act — Elective Option tiers →
Rulebook: DOJ/DON Public Guidance on the Elective Option — a 3x2 grid by exposure duration and injury tier.
Referee: Navy Camp Lejeune Claims Unit checks documentation sufficiency against the chart; DOJ Torts Branch authorizes; claimant has 60 days to accept.
9/11 Victim Compensation Fund + WTC Health Program →
Rulebook: Zadroga Act (as amended, authorized through 2090); 28 CFR Part 104; VCF Policies & Procedures; 42 CFR Part 88 WTCHP.
Referee: 2-stage government grading — NIOSH/WTCHP certifies the condition (or denies, with appeal), then the VCF Special Master issues a separate written eligibility decision.
State workers' comp impairment rating (AMA Guides) →
Rulebook: Deliberately fragmented by state — ~18 states + FECA + DBA use AMA Guides 6th; California uses 5th (Lab Code §4660).
Referee: State WC judge / appeals board accepts or rejects; opposing party buys a rebuttal IME. In Texas the Designated Doctor's opinion carries presumptive weight.
California QME / AME med-legal record review →
Rulebook: 8 CCR §9793-9795 Medical-Legal Fee Schedule; Lab Code §4628, §4062.3; AMA Guides 5th ed (CA is locked to 5th).
Referee: Claims admin can refuse payment; QME deposed (ML204 $455/hr); WCAB judge accepts or rejects as substantial medical evidence.
OWCP / FECA — Statement of Accepted Facts →
Rulebook: 5 USC §8101 et seq; 20 CFR Part 10; FECA Procedure Manual Parts 2 & 3; AMA Guides 6th ed mandatory for schedule awards.
Referee: The Employees' Compensation Appeals Board routinely vacates decisions when the SOAF was incomplete or omitted a material fact.
Black Lung Benefits Act →
Rulebook: 20 CFR Part 718 — Appendices A-C specify exact PFT and ABG numeric thresholds by height and age; 30 USC §921(c)(4) 15-year rebuttable presumption.
Referee: District Director → DOL OALJ → Benefits Review Board → Court of Appeals; a mis-selected exhibit is fatal to the appeal. Approval rate roughly a third.
EEOICPA Parts B & E (energy employees) →
Rulebook: 20 CFR Part 30; 42 CFR Part 82 (dose reconstruction) and Part 81 (IREP probability of causation — ≥50% PoC is compensable, a literal statistical model).
Referee: District Office Recommended Decision → Final Adjudication Branch hearing → written findings on each contested fact → district court.
California IMR / workers' comp utilization review →
Rulebook: Labor Code §4610 / §4610.5-4610.6; 8 CCR §9792.6-9792.12; MTUS incorporating ACOEM Practice Guidelines + MTUS Drug Formulary.
Referee: Maximus issues a written determination with an explicit guideline citation, and DWC publishes the statewide overturn rate annually.
RECA — Radiation Exposure Compensation Act (reauthorized) →
Rulebook: 42 USC §2210 note; 28 CFR Part 79, enumerating by disease exactly what pathology/diagnostic evidence is acceptable; reauthorized 2025.
Referee: DOJ Civil Division issues a written approval or denial specifying the evidentiary deficiency, with administrative appeal and re-filing — binary and itemized.
Longshore (LHWCA) & Defense Base Act →
Rulebook: 33 USC §901 et seq; 42 USC §1651 (DBA); 20 CFR Parts 701-704, 702; §908(c)(13)(E) statutorily mandates the AMA Guides for hearing loss.
Referee: District Director informal conference → DOL OALJ formal hearing → Benefits Review Board → Court of Appeals, each producing a written decision.
Mass tort settlement matrix scoring (claims administration) →
Rulebook: Court-approved Allocation Methodology / MSA exhibits + Case Management Orders (e.g. point-grid injury matrices).
Referee: Claims Administrator scores → reconsideration → court-appointed Allocation Special Master re-review → defendant audit rights.
Asbestos bankruptcy trust claims (TDP packages) →
Rulebook: Each trust's own Trust Distribution Procedures — a literal disease-level payment table.
Referee: Trust claims-processing facility grades against the TDP grid; trusts run statistical audits and can suspend a firm's filing privileges.
VICP — vaccine injury compensation ('vaccine court') →
Rulebook: Vaccine Injury Table, 42 CFR §100.3 — a literal 3-column table (vaccine, injury, time interval for onset).
Referee: Special Masters of the US Court of Federal Claims, in written, published, citable decisions, reviewable by a CFC judge then the Federal Circuit.
Sexual abuse survivor trusts & diocesan claims programs →
Rulebook: Trust Distribution Procedures + Claims Matrix — tiers by act severity, each with a base and maximum value, plus aggravating factors.
Referee: A named Claims Administrator under a retired federal judge as Trustee, with an Independent Reviewer role adjudicating disputes.
State medical board licensure investigations →
Rulebook: The state medical practice act and the board's own regulations, which define unprofessional conduct and the documentation a licensee must keep.
Referee: The board's investigator and its expert reviewer, who read the charts and write the report the board votes on.
Hospital peer review, OPPE / FPPE & credentialing →
Rulebook: The Joint Commission Medical Staff standards requiring ongoing professional practice evaluation (OPPE) and focused professional practice evaluation (FPPE) for every privilege granted.
Referee: The peer review or medical executive committee, which votes on the finding and the privilege recommendation.
RCA / sentinel event review / Patient Safety Organizations →
Rulebook: The Joint Commission Sentinel Event Policy, which requires a comprehensive systematic analysis and an action plan, generally within 45 days of the event becoming known.
Referee: The Joint Commission, which reviews the thoroughness and credibility of the analysis and the action plan.
Pennsylvania certificate of merit (Rule 1042.3) →
Rulebook: Pa. R.C.P. 1042.3, which requires a certificate with the complaint or within sixty days, in one of three alternative forms.
Referee: The court of common pleas, which enters judgment of non pros on praecipe under Rule 1042.7 once the Rule 1042.6 notice has run.
Texas Chapter 74 expert report →
Rulebook: Tex. Civ. Prac. & Rem. Code §74.351, which requires a served expert report and CV carrying the three opinions named in subsection (r)(6).
Referee: The trial court, which dismisses with prejudice and awards attorney's fees if no report is served within 120 days of a defendant's answer.
Florida presuit medical expert opinion →
Rulebook: Fla. Stat. §766.203(2), which requires a verified written medical expert opinion corroborating reasonable grounds, served with the notice of intent.
Referee: The court on a §766.206 presuit review, which may dismiss the claim or report counsel to The Florida Bar.
Georgia §9-11-9.1 expert affidavit →
Rulebook: O.C.G.A. §9-11-9.1, which requires an affidavit setting out at least one negligent act or omission and the factual basis for it.
Referee: The trial court, which dismisses under §9-11-9.1(e) unless the affidavit was filed or the (b) grace period applies.
Illinois 2-622 affidavit and written report →
Rulebook: 735 ILCS 5/2-622, which requires an attorney affidavit plus a separate written health-professional report for each defendant named.
Referee: The circuit court, which dismisses under 735 ILCS 5/2-619 where the report is missing or the reviewer is not qualified under 5/8-2501.
Michigan affidavit of merit (MCL 600.2912d) →
Rulebook: MCL 600.2912d, which requires an affidavit signed by a health professional who meets the MCL 600.2169 matching requirements.
Referee: The circuit court, which treats a complaint filed without a conforming affidavit as failing to toll the limitations period.
Ohio affidavit of merit (Civ. R. 10(D)(2)) →
Rulebook: Ohio Civ. R. 10(D)(2), which requires one affidavit relative to each defendant, from an affiant who attests they reviewed the applicable medical records.
Referee: The court of common pleas, which dismisses under 10(D)(2)(d) where no conforming affidavit or extension motion was filed.
North Carolina Rule 9(j) certification →
Rulebook: N.C. R. Civ. P. 9(j), which requires the complaint itself to assert that the records reasonably available were reviewed by a person reasonably expected to qualify.
Referee: The superior court, which dismisses a complaint lacking the certification and has no discretion to excuse it.
New Jersey affidavit of merit (2A:53A-27) →
Rulebook: N.J.S.A. 2A:53A-27, which requires an affidavit from an appropriately licensed person within sixty days of the answer, specialty-matched under the Patients First Act.
Referee: The Law Division at the Ferreira conference, where a missing affidavit is treated under 2A:53A-29 as a failure to state a cause of action.
Delaware affidavit of merit (18 Del. C. §6853) →
Rulebook: 18 Del. C. §6853, which requires an affidavit of merit and the expert's current CV filed under seal with the complaint.
Referee: The Superior Court prothonotary, who will not docket a healthcare negligence complaint that arrives without the affidavit.
Medical examiner / coroner case review + NVDRS →
Rulebook: The US Standard Certificate of Death and the CDC/NCHS cause-of-death certification guidance, which define the causal sequence and the manner categories.
Referee: The certifying pathologist, whose signature carries the cause and manner determination.
Maternal mortality & fatality review committees →
Rulebook: The CDC Maternal Mortality Review Information Application (MMRIA) data dictionary, which defines the case narrative structure and every coded field.
Referee: The maternal mortality review committee, which votes on pregnancy-relatedness, preventability, and contributing factors.
ERISA / long-term disability claim file review & appeals →
Rulebook: 29 CFR §2560.503-1 full-and-fair-review (2018 amendments require the plan to address every piece of evidence); ERISA §502(a)(1)(B).
Referee: A federal judge, on the administrative record, in a written opinion — plus DOL/EBSA audits.
Long-term care insurance — claims eligibility & recertification →
Rulebook: IRC §7702B(c), the federal statutory definition of "chronically ill individual" (2-of-6 ADLs / 90 days / severe cognitive impairment).
Referee: Denial → internal appeal → independent third-party review (mandated in many states) → DOI complaint → litigation.
IROs / state-mandated external appeals →
Rulebook: 45 CFR 147.136; NAIC Uniform Health Carrier External Review Model Act; state IRO statutes.
Referee: State DOI audits of IRO decision files; URAC re-accreditation every 3 years; published overturn-rate databases.
FMLA / ADA accommodation medical certification review →
Rulebook: 29 CFR §825.305 through §825.308 — the certification, authentication, clarification, second and third opinion rules, and the recertification limits.
Referee: The Department of Labor Wage and Hour Division, which investigates interference and retaliation complaints.
Lien resolution & Medicare Secondary Payer compliance →
Rulebook: 42 USC §1395y(b) + 42 CFR Part 411; Ahlborn (2006) & Gallardo (2022) for Medicaid; ERISA §502(a)(3); Section 111 reporting.
Referee: CMS BCRC/CRC accepts or rejects every disputed line in writing, then a 5-level appeal ladder.
Medicare Set-Aside (WCMSA / LMSA) allocation →
Rulebook: CMS WCMSA Reference Guide v4.x; 42 USC §1395y(b); 42 CFR §411; CDC Life Table Table 1; Section 111 reporting.
Referee: CMS Workers' Comp Review Contractor (Capitol Bridge) issues a written approval or counter-higher with a dollar number.
Structured settlement rated-age underwriting →
Rulebook: Each carrier's substandard annuity manual (debit table over 2012 IAM / a2000 with an improvement scale); 50-state structured settlement protection acts.
Referee: Submit one packet, get 4-8 independent rated ages back within 24-72 hours — the carrier spread is a direct quality score on the packet.
Life insurance underwriting — APS summarization →
Rulebook: The carrier's own underwriting manual — Swiss Re Life Guide, Munich Re ALLFINANZ/MIRA, RGA GUM, Gen Re GUM — literal debit/credit tables.
Referee: Post-issue audit, mortality slippage tracking, and reinsurance treaty audits.
Life settlement / viatical life expectancy underwriting →
Rulebook: 2015 VBT / 2008 VBT base tables; ASOP No. 48 (Life Settlement Mortality); AM Best rating criteria require at least 2 independent LE providers.
Referee: The insured either dies or doesn't — every LE is graded by an Actual-to-Expected deaths ratio computed by third-party auditors.
Life claims contestability / rescission review →
Rulebook: The incontestability clause (statutory 2-year period in every state); state materiality standards.
Referee: Rescission is challenged in court whenever economically worthwhile; courts issue written opinions on materiality, and ACLI publishes scoreboard data.
Medical stop-loss / shock-claim underwriting →
Rulebook: The carrier's own disclosure form and underwriting manual, which define what must be disclosed and how a large claimant is evaluated.
Referee: The stop-loss underwriter, who prices the layer and sets any laser.
Insurance SIU — medical provider fraud & staged accidents →
Rulebook: State insurance fraud statutes and mandatory referral rules (e.g. NY 11 NYCRR 86, CA Ins. Code §1872.4, FL §626.989); NAIC Model #680.
Referee: Criminal referral → indictment → conviction; civil RICO recovery; state DOI fraud-bureau disposition statistics published annually.
No Surprises Act Independent Dispute Resolution (IDR) →
Rulebook: 45 CFR §149.510(c)(4)(iii)(C): level of training/experience/quality outcomes, patient acuity/complexity, teaching status/case mix.
Referee: The IDRE picks one of 2 offers — binary, in writing, within days — and CMS publishes every determination in quarterly reports.
Medicare audit response — TPE, UPIC, SMRC, RAC, ADR →
Rulebook: CMS Program Integrity Manual (Pub. 100-08) Ch. 3 & 8 — the 45-day ADR clock.
Referee: Contractor decision, then the 5-level appeal ladder: MAC redetermination → QIC reconsideration → OMHA ALJ → Medicare Appeals Council → federal court.
DRG downgrade / clinical validation appeals →
Rulebook: The ICD-10-CM Official Guidelines for Coding and Reporting, which govern when a diagnosis may be coded from the record.
Referee: The payer's medical director, who decides the first-level appeal.
CMS RADV audit response →
Rulebook: The CMS RADV medical record reviewer guidance, which defines an acceptable record: valid provider type, face-to-face encounter, date of service in the data year, and a legible signature and credential.
Referee: The CMS RADV medical record reviewer, who accepts or rejects each submitted record.
HCC risk adjustment retrospective chart review →
Rulebook: The ICD-10-CM Official Guidelines for Coding and Reporting, including the requirement that a condition be documented as monitored, evaluated, assessed or treated in a face-to-face encounter.
Referee: The CMS RADV medical record reviewer, who tests the same charts against the same guidance.
HEDIS / NCQA hybrid chart abstraction →
Rulebook: The NCQA HEDIS Technical Specifications for the measurement year, which define each measure's numerator, denominator, exclusions and allowable data sources.
Referee: The NCQA-certified HEDIS compliance auditor, who validates the medical record review and can invalidate a measure.
Payer-side payment integrity clinical review →
Rulebook: The plan's own medical policy and the licensed criteria set it names — the published screening criteria the determination must be measured against.
Referee: The plan's medical director, who makes and signs the medical necessity determination.
CLINICAL & REGULATORY PROGRAMS
15Cancer registry abstraction (CTR, NCDB, CoC) →
Rulebook: STORE (NCDB); SEER Program Coding and Staging Manual; NAACCR Data Standards; AJCC Cancer Staging Manual 8th ed.
Referee: CoC surveyor site visit every 3 years with live case review; NCDB hard-edit rejects against the published edit set.
Hospice eligibility / terminal prognosis documentation →
Rulebook: Medicare Benefit Policy Manual Ch. 9 §20; 42 CFR 418.22/418.25; disease-specific hospice LCDs.
Referee: TPE/UPIC/SMRC/RAC review decisions with published round-by-round denial rates; OIG hospice work plan.
Cardiac & stroke registry abstraction (STS, NCDR, GWTG) →
Rulebook: The STS National Database data specifications for the applicable harvest, with their own definitions and coding instructions per field.
Referee: The registry's data quality audit, which re-abstracts sampled cases and scores agreement.
Trauma registry abstraction (NTDB / TQIP) →
Rulebook: The National Trauma Data Standard data dictionary for the admission year, which defines inclusion criteria and every element.
Referee: The American College of Surgeons verification review team, which examines registry completeness and accuracy on site.
Clinical Endpoint Adjudication Committees (CEC) →
Rulebook: The adjudication charter, which defines the endpoint definitions, the required source documents, and exactly what must be redacted to preserve blinding.
Referee: The Clinical Endpoint Committee, whose blinded adjudication is the outcome of record.
SNF MDS 3.0 / PDPM validation →
Rulebook: The CMS Long-Term Care Facility RAI User's Manual, which defines every MDS item, its look-back period, and its coding instructions.
Referee: The MAC and the Supplemental Medical Review Contractor, on targeted probe and educate and on additional documentation requests.
FAA special issuance / HIMS pilot medical certification →
Rulebook: 14 CFR Part 67, which sets the medical standards for first, second and third class certificates.
Referee: The Federal Air Surgeon's office and the Aerospace Medical Certification Division, which issue, defer or deny.
Home health OASIS review →
Rulebook: The CMS OASIS Guidance Manual, which defines each item, its time point, and its response-specific instructions.
Referee: The MAC and the UPIC, on additional documentation requests and targeted probe and educate.
Correctional healthcare consent-decree chart audits →
Rulebook: The consent decree or settlement agreement itself, with its enumerated performance measures and compliance thresholds.
Referee: The court-appointed monitor, whose periodic reports state the compliance rating for each measure.
NHSN healthcare-associated infection surveillance →
Rulebook: The NHSN Patient Safety Component manual for the surveillance year, with its device-associated and procedure-associated event definitions.
Referee: The state health department's NHSN validation audit, which re-reviews charts and scores agreement.
DOT medical examiner certification (FMCSA complex certs) →
Rulebook: 49 CFR §391.41, the physical qualification standards a commercial driver must meet.
Referee: The certified medical examiner on the National Registry, who signs the certificate and stakes their listing on it.
Pharmacovigilance / ICSR case processing →
Rulebook: ICH E2B(R3), which defines the individual case safety report data elements and the narrative's place among them.
Referee: The regulator receiving the report — FDA, EMA, or the national competent authority — whose inspectors read the narrative against the source.
Medical device complaint handling & MDR reportability →
Rulebook: 21 CFR Part 803, the medical device reporting regulation, with its serious injury and malfunction definitions and its 30-day and 5-day clocks.
Referee: The FDA investigator on a QSR inspection, who reads complaint files and the reportability rationale behind each one.
Organ procurement (OPO) donor eligibility review →
Rulebook: OPTN policy, including the donor medical and behavioural history requirements and the risk criteria for disease transmission.
Referee: The OPTN and its Membership and Professional Standards Committee, which review policy compliance.
Regulatory medical writing — CSR patient narratives →
Rulebook: ICH E3, which specifies the clinical study report structure and what a patient narrative must cover.
Referee: The regulator's reviewer at submission, who reads narratives against the tabulated data.
Bring us the rulebook.
If your case type has a published standard and someone who grades the file against it, send us one real file. We will tell you what we can extract, what we would have to build, and what it would cost.
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