A claims compliance audit of every closed claim — each deadline tested, each late step priced, each exception confirmed by a reviewer
Every closed claim checked, not the few dozen a reviewer can sample.
See one case, screen by screen ↓Software that tests claims handling against the fair claims rules a regulator examines: acknowledgment, investigation, decision and payment deadlines, and what a denial letter must say. Claims Compliance Audit tests every closed claim rather than a sample, cites each step to its file page, and has a reviewer confirm every exception.
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Every state's fair claims rules put clocks on a claim: acknowledge it, begin the investigation, accept or deny it, pay it, and explain any denial in writing with the reason, the policy provision and the regulator's review notice. Claims compliance tests those clocks by pulling a few dozen closed files a quarter, dating each step by hand from the notes and letters, and writing up what the sample shows.
The examiner pulls the whole claims population by data call. So the late status letters and the denial letters missing a review notice turn up in the exam, not in the quarterly memo. And when a sample does find errors, counting them points the fix at the most frequent one, not at the one that carries the most exposure.
Estimated split for one quarter's claims compliance testing and an exam data call response, by hand and with the solution.
Six specialist agents read every closed file, test each fair claims step and price every late one; a compliance reviewer confirms each exception.
Ashgrove Mutual Insurance Group closed 14,286 claims in California, Texas, Florida and New York in the third quarter. The California Department of Insurance has sent a claims data call, due October 30. Here is what happens, screen by screen, in the working solution.
The file reader works through 14,286 closed files and 1,962,410 pages, dating every step and citing it to its page. The clock checker tests 58,571 steps against California v7, Texas v5, Florida v9 and New York v4. The letter checker reads 3,234 denial letters and finds 83 missing required content. The exposure pricer prices 559 late or missing steps, and the pattern finder ranks 11 patterns by money at risk.
The last line of the run is a person: “Lena Hoshino confirms — 331 exceptions waiting · 212 confirmed.”
Lena opens the strip wall: every closed claim of the quarter as a pixel, by state and by the week it closed — California 121 late, Texas 137, Florida 41, New York 260. Beside it, each claim is a strip of five dots — acknowledge, investigate, decide, pay, explain denial — placed on the day the step happened, with a tick for the state's deadline. On the right, $1,218,920 at risk, ranked by fix.
“Last quarter's sample: 60 files, 2 exceptions.”
CLM-CA-26-118427, Marisol & Ethan Prescott, homeowners, Chico. Proof of claim came on Jul 22, so California's 40 days ended Aug 31; the decision went out Sep 9. Lena clicks the red Decide dot and reads the rule, the three dates and the exposure: $5,000, up to $5,000 per act, non-willful, under Cal. Ins. Code §790.035(a).
“No written status letter between Jul 22 and Sep 9 (file pages 32–37).”
The strip is drawn large: each deadline window from its starting event, the proof-of-claim line on Jul 22, and the red overrun from Aug 31 to Sep 9. Below it, the file itself — 13 documents, 42 pages — from the first notice of loss to the contractor estimate of $31,470.00 that started the 40-day decision clock. Claimed $31,470.00, paid $18,640.22, denied $12,829.78.
Two red margin notes sit in the file where the clock passed: day 30 from proof of claim on Aug 21, when a written status letter was due, and day 40 on Aug 31, the decision deadline. The letter checker confirms the Sep 9 partial denial gives the reason, section I.C.8 and the review notice — so the denial letter passes, and only the decision is late. The agents' run on this file is shown step by step, with a re-check button.
The clock checker is fixed rules: the same dates always give the same result, and it never excuses a late step.
Nothing is an exception until a reviewer says so. Lena can confirm it, send it to Dev Ramaswamy, the team lead, or overturn it — and overturning asks why: the insured asked for more time in writing, the agent read the wrong date, or the claim is outside the audit. She confirms the Prescott claim: $5,000 at risk, added to the exam pack.
“Overturning takes it out of the money at risk. The reason is kept with the file and shown in the exam pack.”
The exceptions queue holds all 559: 331 to confirm, 212 confirmed, 16 overturned. Each row names the step, what happened, the due and done dates, the cite, the days late, the team and the money at risk — the Texas commercial property payments made more than 5 business days after the acceptance letter, under Tex. Ins. Code §542.057(a), sit at the top. Reviewers filter by state and pattern, select and confirm in a batch.
Counted, New York auto acknowledgments come first: 211 claims, $105,500. Priced, California homeowners decided past 40 days with no status letter come first: 63 claims, $315,000 — third by count. Each of the 11 patterns carries why it happens, the fix and the teams; Marcus assigns the status-letter fix — a day-30 diary from proof of claim — to Dev Ramaswamy.
“Counting errors puts the wrong fix first; pricing them does not.”
Late or missing steps per 1,000 closed claims, by team and step: Albany Auto Team 2 at 148.5 on acknowledgments, Sacramento Property Team 3 at 42.2 on decisions, Austin Commercial Property at 38.4 on payments. Week by week by state, and by line — homeowners carry $560,640 at risk on 155 exceptions.
The exam pack builder assembles the California response in the Department's data call layout: the 5,128-claim population, a result per claim with its page citations, the 121 exceptions with evidence, the rules tested, the corrective actions for patterns 1, 2 and 8, the reviewer log and a draft cover memo. It then goes to Teodor Wills to sign.
“Nothing is sent to the Department until he signs.”
The same quarter, seen by the four people who carry it — what their quarter looked like, and what it looks like now.
Six specialist agents read every closed file, test each fair claims step and price every late one; a compliance reviewer confirms each exception.
Reads every note, letter, estimate and payment in a closed claim file and dates each event — notice, acknowledgment, investigation, proof of claim, decision, payment — with the page it came from.
Applies the state's rule to the dated events — calendar or business days, state holidays, the status-letter extension — and marks each step on time, within 2 days, late or not applicable.
Reads denial and status letters for what the state requires: the specific reason, the policy provision and the regulator's review notice — and looks for status letters between proof of claim and the decision.
Prices each late or missing step from the approved exposure schedule — per-act caps, statutory interest on the claim, the attorney's-fee allowance — and shows the arithmetic and the source on every amount.
Groups exceptions into root causes by state, line, team, step and letter template, reads the claim notes for why the step slipped, and ranks the fixes by money at risk with the count rank beside it.
Assembles the evidence pack for a market conduct exam in the regulator's data call layout: population, results, exceptions with their file pages, corrective actions, the reviewer log and a cover memo.
Confirms each exception; the VP, Compliance signs the exam pack. The agents propose; a named person decides.
The claims compliance team can ask in plain words — or tell it what to change. Answers name the rule and the file pages they rest on.
Why is the Prescott claim an exception?
Because the decision was 9 days late with no status letter. Proof of claim came on Jul 22 (contractor estimate, file p. 19–31), so California's 40 days ended Aug 31. The partial denial went out Sep 9 (p. 38–40). A written status letter was due by day 30 if more time was needed — there is none between p. 32 and p. 37. Exposure: $5,000, per act, non-willful. Everything else on the strip is on time.
Which fix saves the most money at risk?
Pattern 1: California homeowners decided past 40 days with no status letter — 63 claims, $315,000. 41 are in Sacramento Property Team 3 and 22 in Fresno Property Team 2. The fix is a status letter diaried at day 30 from proof of claim. It was also a finding in the 2023 California exam. By count it is only third.
Rank the patterns by count instead
By count, New York auto acknowledgments come first — 211 claims — but they carry $105,500 on the compliance schedule, fifth by money. California's 63 status-letter claims carry three times as much.
Build the California exam pack
Building it now: the population of 5,128 California claims, every result with its page citation, 121 exceptions with evidence, rules v7, the corrective actions for patterns 1, 2 and 8, and the cover memo. It goes to Teodor Wills to sign; nothing is sent to the Department before that.
12 screens from the working solution, on its sample data. Pick one to see it large.
What a late step costs, who confirms, and when the check runs are settings — changed by proposal and approved by the VP, Compliance.
| Setting | Default | Choose from |
|---|---|---|
| Check every closed claim | Nightly at 02:00 | On · Off — claims closed the day before |
| Re-check the quarter | 5th of each month | Against the rules in force |
| Show steps within a margin of the deadline | 2 days | On · Off — amber dots pass and show the margin |
| Price willful violations | Off | On · Off — non-willful unless a reviewer marks a file willful |
| Tell team leads at day 30 on undecided claims | On | On · Off — before the 40-day line |
| Exposure basis per state | CA $5,000 per act · TX 18% a year interest · FL $5,000 per act · NY $500 per late step, $1,000 per incomplete denial | Statutory cap · statutory interest · your own estimate |
| Attorney's-fee allowance, Texas | $350 per late file | From your litigation history |
| Lines in scope | Auto, homeowners, commercial property | Workers' compensation joins in Q1 2027 |
Every figure is labelled: a target the solution is built to, an estimate, a typical published result, or a proven one.
“demo” = seen in the working solution, on its sample quarter of closed claims · “target” = the design goal, measured in the live solution · “estimated” = our estimate · “typical” = published figures (NAIC Market Regulation Handbook — the claims error tolerance). Rules and penalty bases shown in the working solution: 10 CCR §§2695.5, 2695.7 and Cal. Ins. Code §790.035 · Tex. Ins. Code ch. 542 · Fla. Stat. §§627.70131, 624.4211 · 11 NYCRR Part 216; New York amounts are a compliance-team schedule, not statutory caps. People, companies and claims named on this page are fictional — characters and sample data in the working solution.
Software that tests claims handling against the fair claims rules a regulator examines: acknowledgment, investigation, decision and payment deadlines, and what a denial letter must say. Claims Compliance Audit tests every closed claim rather than a sample, cites each step to its file page, and has a reviewer confirm every exception.
The file reader dates each event in the file — notice, acknowledgment, investigation, proof of claim, decision, payment — with the page it came from. The clock checker applies that state's rule set — calendar or business days, state holidays, the status-letter extension — and the letter checker reads denial and status letters for the reason, the policy provision and the review notice.
The exposure pricer applies each state's basis from an approved exposure schedule: a per-act cap such as California's up to $5,000 non-willful, statutory interest such as Texas's 18% a year, or the compliance team's own schedule where no statute sets an amount. Each amount shows its basis and source, and it is an estimate, never called a fine.
No. It finds and prices late or missing steps; a claims compliance reviewer confirms each exception or overturns it with a reason — tolling, a wrong date read, or a claim outside the audit. A written request for more time is flagged for a reviewer and never excuses a step on its own.
The exam pack builder assembles the response in the regulator's data call layout: the claims population, the result per claim with page citations, the exceptions with evidence, the rules tested, corrective actions, the reviewer log and a cover memo. It never sends anything; the VP, Compliance signs first.
Every night at 02:00 on the claims closed the day before, and the whole quarter is re-checked on the 5th of each month against the rules in force. Team leads can be told at day 30 on undecided California claims, before the 40-day line.
Yes. A reviewer confirms every exception, a person assigns every fix, and the VP, Compliance approves every rule version and the exposure schedule and signs every exam pack. Claims team leads see their own team's strips but cannot change results.
The Agentic Solution Engine builds and deploys it from your requirements and documents — your states' rules, your exposure schedule, prior exam findings and a sample of closed claim files — and it goes live once every quality gate has passed. We will walk you through it on a quarter of your own closed claims first.
Each new rule mapped to its policy and owner the day it is published.
1-min demo50-State Regulatory ResearchEvery state answered side by side, each with the statute that says so.
1-min demoMarket Conduct Exam ManagementEvery examiner request tracked to its due date, answered from the file.
1-min demoWe'll run Claims Compliance Audit on a quarter of your own closed claims.