UPL Compliance

The UPL Zone System

Every AI interaction in AdjudiCLAIMS is classified into one of three zones that determine what the AI can say, what it must disclaim, and what it must block.

Why This Exists

California Business & Professions Code § 6125 prohibits the unauthorized practice of law. Claims examiners are not attorneys. An AI product that provides legal analysis, coverage opinions, or settlement recommendations to non-attorneys violates this statute.

AdjudiCLAIMS enforces UPL boundaries automatically through a three-stage pipeline — not through a policy document, but through code. The system cannot give legal advice to examiners. This is a hard technical constraint.

⚖ Cal. Bus. & Prof. Code § 6125

The Three Zones in Detail

GREEN ZONE — Fully Permitted

The GREEN zone covers factual data retrieval, arithmetic calculations, document summarization, and regulatory citation. The AI can answer these questions directly without disclaimer.

✓Medical record summaries and WPI extractions

✓Benefit calculations (TD rate, payment schedules)

✓Statutory deadline tracking with citations

✓Document classification and field extraction

✓AWE calculation from pay stubs

✓Injury chronology and fact patterns

✓Investigation checklist status

✓MTUS guideline matching for UR

Example GREEN response

"The QME report dated 2025-03-01 (Dr. Martinez, page 4) states 12% WPI for the lumbar spine under AMA Guides 5th Edition, Table 15-3. Based on the DOI of 2024-06-15 and this WPI, the TD period runs through the date of P&S (LC 4650)."

YELLOW ZONE — Disclaimer Required

The YELLOW zone covers statistical data and legal-adjacent information. The AI can present this data but must append a mandatory disclaimer directing the examiner to consult defense counsel before acting on it.

⚠Comparable claims resolution ranges

⚠Medical inconsistency flags (statistical)

⚠Litigation indicator patterns

⚠Reserve adequacy benchmarks

⚠Denial/delay rate comparisons

⚠Industry-wide settlement percentiles

Example YELLOW response (mandatory disclaimer)

"Statistical data: comparable lumbar spine claims with 10–14% WPI in Los Angeles County resolved in the $45,000–$85,000 range (25th–75th percentile, 2023–2025 data).

⚠ Disclaimer: This is statistical data only, not a settlement recommendation. Consult defense counsel before using this information in reserve discussions or negotiations."

RED ZONE — Blocked

The RED zone covers legal analysis and advice. These queries are blocked before any AI processing occurs. The examiner receives an attorney referral response, not an answer.

🛑Coverage opinions and compensability determinations

🛑Settlement recommendations or valuations

🛑Case law interpretation

🛑Liability analysis

🛑Outcome predictions ("this claim will settle for...")

🛑Legal strategy advice

🛑Work product analysis

🛑Expert witness selection

Example RED response (blocked)

"🛑 This question requires legal analysis by a licensed attorney and cannot be answered by AdjudiCLAIMS. Please contact your defense counsel for guidance on coverage questions, settlement strategy, and compensability determinations. Cal. Bus. & Prof. Code § 6125."

Three Independent Enforcement Layers

The zone classification is not a policy — it's three separate technical mechanisms. All three must pass.

Query Classifier

Lightweight pre-chat LLM call classifies the query before any document retrieval. RED queries stop here.

System Prompt

Role-specific system prompt enforces zone boundaries and prohibits legal analysis language patterns.

Output Validator

24+ post-generation pattern checks. Even if stages 1 and 2 passed, prohibited output patterns trigger a block.

Verified Against 517 Test Fixtures

126

RED queries

100% blocked

126

GREEN queries

0% false positive blocks

YELLOW queries

100% include disclaimer

203

Output variations

100% caught by validator