Fifty-seven case types. Every one runs on a published rulebook and a named referee.
We screen a case type on three 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 fifty-seven pass. Thirty-one have a page naming their rulebook and referee outright. The rest are screened and listed here — bring us one and we will scope the build.
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
Consultative examinations — a two-page record digest handed to the examining physician before a twenty-minute exam.
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: Two-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 three-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
Standard-of-care review across multiple patient charts and prescribing records, for boards and for licensee defense.
Hospital peer review, OPPE / FPPE & credentialing
Case abstraction for professional practice review, with the peer-review privilege question addressed in the engagement.
RCA / sentinel event review / Patient Safety Organizations
The full chart, policies and device logs assembled into a systematic analysis inside the reporting window.
Medical examiner / coroner case review + NVDRS
Decedent history synthesis for cause and manner determination, and violent death reporting abstraction.
Maternal mortality & fatality review committees
The committee case narrative, abstracted to the national data dictionary.
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
The escalated subset only: second and third opinions, intermittent-leave patterns, interactive-process documentation.
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 two 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
Disclosed large claimants read for trajectory, treatment regimen, and transplant candidacy ahead of a laser decision.
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 two 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
The rebuttal letter built from chart evidence, coding guidance and the payer's own clinical criteria.
CMS RADV audit response
Selecting the one best record per sampled condition, against CMS reviewer guidance, on a five-month clock.
HCC risk adjustment retrospective chart review
Supported-diagnosis abstraction with page-cited proof for encounter submission.
HEDIS / NCQA hybrid chart abstraction
Numerator evidence and service dates for measure validation.
Payer-side payment integrity clinical review
Itemized bill audit and medical necessity determination against published care guidelines and plan policy.
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)
Cath, surgery and stroke registries — data-standard elements and outcome coding.
Trauma registry abstraction (NTDB / TQIP)
Data-standard elements and injury severity coding.
Clinical Endpoint Adjudication Committees (CEC)
De-identified, redacted, chronologically ordered event packets for blinded committee review.
SNF MDS 3.0 / PDPM validation
Function, diagnosis and service items validated against the supporting documentation, with the payment regrade.
FAA special issuance / HIMS pilot medical certification
The special issuance evidence packet the certification division issues, defers, or denies against.
Home health OASIS review
Every OASIS item checked against the documentation behind it, with the clinical grouping and payment delta.
Correctional healthcare consent-decree chart audits
Chart audits against the decree's own enumerated performance measures, for court-appointed monitors.
NHSN healthcare-associated infection surveillance
Culture-triggered chart review against the national surveillance definitions.
DOT medical examiner certification (FMCSA complex certs)
Specialist evidence packets for the conditional and complex subset of examinations.
Pharmacovigilance / ICSR case processing
Source documents to a chronological, source-faithful case narrative.
Medical device complaint handling & MDR reportability
Clinical records behind a complaint read for the reportability rationale under 21 CFR Part 803.
Organ procurement (OPO) donor eligibility review
Medical and social history review for the donor risk assessment and transplant network documentation.
Regulatory medical writing — CSR patient narratives
Patient narratives for deaths, serious adverse events and discontinuations, to the clinical study report standard.
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.
Test a file