Care coordination and transitions

Status: DETAILED MEDICAL OPERATING SOP DRAFT — human-readable clinical workflow; not yet clinically or operationally approved

CMS baseline: GUIDE RFA Appendix B, Section 5 ↗. The Proxi column identifies candidate automation, not functionality already deployed. The executed GUIDE Participation Agreement remains the final requirements check before these tasks are used in the field.

The inventory separates Proxi-paid human entry from beneficiary, caregiver and outside-provider actions. A clear beneficiary choice is not navigator labor. A connected scheduling or records transaction is not a human service merely because a person receives its result. The detailed cards control the exact human act and its conditional entry.

Medical SOP purpose and scope#

This SOP describes four coordination procedures; most preparation and logistics are nonclinical:

1. coordination with a beneficiary's PCP when the PCP is outside the GUIDE care team;
2. referral to and closed-loop coordination with a specialist or other clinical provider;
3. support during a transition between the beneficiary's residence and a hospital, emergency department, nursing facility, hospice, or another care setting; and
4. other clinical coordination needed to manage dementia or a co-occurring condition across the care continuum.

Community-resource and Medicaid HCBS connection work is detailed separately in 15_SOP_Referral_and_Services.md. A safety concern is an interrupt to any coordination route, not a separate referral type.

CMS establishes the Section 5 obligations. The handoff packet, role sequence, teach-back practice, proposed 48-to-72-hour recovery contact, and detailed closure criteria below are Proxi clinical operating design informed by AHRQ transition-safety guidance; they are not additional CMS requirements. Numeric operating clocks remain proposed until O-004 is approved.

Under D-012, Proxi supplies or contracts the required in-scope navigator and clinical labor through the approved Participant and Partner Organization arrangement. Institutional Participant accountability does not make this labor free or move every review to an unspecified Participant employee. A genuinely retained act must be established from the executed Agreement and assigned under O-PA-001. External PCPs, specialists, facilities, pharmacies and emergency services retain their own source, treatment, discharge, dispensing and emergency acts; Proxi cannot assign or attest those acts unilaterally.

What GUIDE requires, and what Proxi adds#

These are service obligations and conditional routes, not a requirement to perform every inventory task or contact every provider every month. The same event can produce several real service results with one shared conversation.

Authority and role assignment#

Manual provider-packet sending — D-031. When automated transmission is unavailable, Philippine L1 sends the already-approved coordination request/information packet to its authorized provider, records send/delivery/failure and pursues factual receipt. Clinical content, recipient/purpose/permission and any required human release must already be settled. This does not appoint the O-021 release authorizer, interpret a clinical response, cover O-014 Care Plan distribution or change D-007 community-referral release. Missing authorization holds the affected send; a medical-only question still goes directly to its qualified professional.

Release and packet size. Under D-033, routine requests/information to an authorized provider send automatically when the accepted O-021 class rule establishes the exact content, recipient, purpose, lawful basis/restrictions and channel. No extra human OK is required merely because it is a first packet. A genuinely required case-specific human review still occurs; missing or uncovered authority holds the affected send. Care Plan distribution, community referrals and special/mixed-content classes retain every applicable requirement. Use the smallest approved packet under applicable law/contract and Proxi data-minimization policy. HIPAA minimum necessary does not apply to verified provider-treatment disclosures or requests, but that is not blanket permission. Approval and sending shows the separate tasks and source basis.

The Puerto Rico L2 navigator operation performs no licensed assessment, triage, reconciliation, treatment decision, or individualized clinical instruction. Every such act routes to the separate U.S. clinical workforce. Before that professional acts, confirm the beneficiary's current physical location and the professional's current authority for that jurisdiction and act. If location or authority is unknown, L0-L2 may collect facts and connect the person, but no clinical decision or new instruction may be given through that route. An immediate safety pathway must not be delayed for routine intake questions.

Cross-pillar preparation, no-repeat handoffs, owner acceptance, and shared labor follow 25_GUIDE_Eight_Pillar_Service_Integration.md. Preparation precedes judgment: software and L1 assemble the source-linked packet; L2 enters only under D-021; and a prepared protected question goes directly to the authorized U.S. professional.

Required coordination record#

Every clinical coordination episode must begin with a focused record that contains, as applicable:

• the actual subject of each licensed act and that person's current physical location; distinguish a caregiver merely reporting beneficiary facts from a caregiver receiving a separate clinical assessment, and verify each relevant professional scope and provider-location requirement;
• beneficiary identity, current physical location, current care setting, preferred language and communication accommodations;
• reporter identity, decision or disclosure authority when relevant, callback information, and beneficiary preferences for caregiver participation;
• coordination route, trigger, date and source, specific requested outcome, and why the work is needed now;
• current PCP, relevant specialists, prescribing clinicians, facility or agency contacts, and evidence of each current relationship;
• the exact clinical question or requested action, written by or confirmed with the clinician when medical judgment is involved;
• relevant diagnoses and conditions as documented by their sources, current symptoms or observable changes reported verbatim, and the person's cognitive, functional, and behavioral baseline when material;
• current care-plan reference, beneficiary goals and preferences, and only the care-plan content relevant to the recipient and purpose;
• medication and allergy information relevant to the coordination question, clearly distinguishing reconciled regimen, reported use, and unresolved discrepancies;
• recent encounters, transition information, pending tests or results, follow-up appointments, equipment, home services, and known barriers when applicable;
• every source, author, event date, receipt date, correction, and unresolved conflict; and
• requested response, responsible reviewer, return route, and clinically assigned timing.

Unknown, stale, or conflicting information remains labeled as such. A focused clinical packet is not a full-chart dump. AI-generated summaries remain aids; the original records and source-linked facts accompany any clinical review.

Universal safety interrupt#

If a beneficiary, caregiver, provider, or record raises a possible immediate safety issue, new or worsening symptom, medication problem, abuse or neglect concern, behavioral-health crisis, conflicting clinical instruction, or request for urgent medical advice:

1. L1 or L2 captures the report verbatim, confirms callback information and current location when safely obtainable, and stops ordinary advice or transmission.
2. The approved clinical or emergency pathway is invoked. L1, L2, and AI do not determine urgency, causality, treatment, or disposition.
3. An L3 professional may assess or triage only within beneficiary-location authority and approved scope. L4 or the applicable treating clinician makes medical and treatment decisions; emergency services handle immediate threats.
4. Failed connection is actively escalated; an attempted call is not a completed handoff.
5. The safety disposition and resulting work are recorded separately. Completing the safety handoff does not close the underlying coordination, transition, or medication obligations.

Procedure A — outside-PCP coordination#

1. Confirm the PCP and team relationship. Verify the current PCP, practice, effective relationship, and whether the PCP is outside the GUIDE care team. Unknown membership does not default to outside or inside.
2. Complete the standing GUIDE duties. Confirm the beneficiary's communication preferences and restrictions, verify the PCP endpoint, and prepare the GUIDE participation notice and current care plan for authorized release. Confirm meaningful access to the current plan; a dormant portal, failed transmission, or superseded plan is insufficient.
3. Avoid unnecessary PCP work. Notice, current-plan access, and future plan revisions are standing duties. A stable month does not require an additional PCP call when no specific coordination need exists.
4. Define the need-specific request. When an actual coordination need exists, L0/L1 assembles the source-linked need, beneficiary/caregiver's literal requested result, supporting facts, conflicts, prior attempts, and a draft exact question. A clear nonclinical choice may be confirmed directly. L2 resolves only requested or relationship-dependent ambiguity. L3/L4 validates or changes the clinical question, determines clinical urgency, and exercises the protected judgment; the clinician does not gather the routine supporting record.
5. Prepare and release the focused packet. Proxi verifies the recipient and assembles the exact approved content. Software applies the accepted O-021 class rule. A D-033 routine authorized-provider request/information packet sends automatically with no extra per-packet human OK when every required fact and restriction matches; any genuinely required individual review occurs first. Other classes remain held under their own rule. Neither software nor an unnamed person may substitute a recipient, purpose, channel, or content.
6. Track the response without interpreting it. L0 tracks; L1 pursues administrative nonresponse and records replies verbatim. L1 stops when the reply contains a clinical question, contradiction, new instruction, dispute, or safety concern.
7. Obtain authorized review. Route clinically material information to the professional whose scope covers the question. Receipt is not acceptance, and recency alone does not resolve conflicting clinical positions.
8. Communicate and carry forward. Software may deliver a faithful approved explanation through the permitted accessible route. The clinician authors clinical meaning and answers individualized medical questions; L2 enters only for required/requested nonclinical or accessibility support. Update the care plan or record an authorized reviewed-no-change conclusion, carry each resulting action to its actual performer, and preserve unresolved disagreement.

Outside-PCP foundation — detailed task cards#

These four tasks establish the person, team relationship, communication choices, and usable destination before Proxi prepares the GUIDE notice or current care plan. They are event-driven rather than monthly work. Reopen the affected task when the beneficiary, PCP, care-team roster, participation preference, or routing information changes, becomes stale, conflicts with another source, or fails in use.

The evidence labels below describe what a source actually proves:

• Direct evidence establishes the narrower fact the source records. For example, a Medicaid or managed-care PCP field can directly establish the payer's administrative assignment and effective date, but it does not by itself establish whom the beneficiary regards as the current treating PCP.
• Corroborating evidence supports or challenges a candidate fact but cannot establish that fact alone. Claims establish dated utilization by the named billing or rendering provider, not a current PCP designation.
• Identity-only evidence helps identify or contact a provider. It does not establish a beneficiary relationship, payer assignment, GUIDE-team membership, permission, or a current clinical endpoint.

The labor estimates are provisional Proxi workload-calibration assumptions, not CMS requirements, service clocks, staffing guarantees, or field observations. Clean-path minutes are expected Proxi human labor; automated processing time and beneficiary, representative, practice, or payer time are excluded. All four foundation tasks can be zero Proxi human minutes when current sources yield a prepared candidate packet, the beneficiary/representative supplies a clear authenticated confirmation directly, and the practice-managed endpoint is current. When manual PCP identity, roster, contact, or routing resolution is actually required, use one shared 13-minute Philippines administrative exception allowance for the outside-PCP foundation episode rather than adding 13 minutes to each failed task. L2 time exists only for required/requested human service, ambiguity, disagreement, distress, accessibility failure, no-PCP relationship work, or useful confirmation; it is not a default validation charge. Replace all assumptions with measured pilot data.

Confirm the current PCP#

When. Complete at initial coordination setup; whenever PCP information is missing, conflicting, stale, or reported changed; after a transition that may have changed the primary-care relationship; and before the first outside-PCP GUIDE notice or care-plan exchange.

What and how much. Establish one truthful outcome: (1) current PCP confirmed, including the individual clinician and practice; (2) the beneficiary currently has no PCP; or (3) unresolved. An unresolved result keeps this task open and does not default to the provider seen most often.

Data inputs.

• Direct: the current statement of a capable beneficiary; a representative acting under established authority; authenticated confirmation from the PCP practice; or a current authoritative clinical record that explicitly designates the clinician as PCP. A state or managed-care PCP assignment record is direct only for the administrative assignment it records, not for the beneficiary-identified or actual treating relationship (SRC-NC-MEDICAID-PCP-ASSIGNMENT).
• Corroborating: beneficiary-authorized payer claims, encounters, and payer-maintained clinical data (SRC-CMS-PATIENT-ACCESS-API); Medicare Parts A, B, and D claims available through beneficiary-authorized Blue Button 2.0 (SRC-CMS-BLUE-BUTTON); recent primary-care encounters; referrals; orders; care plans; and HIE records. These can identify candidates or conflicts but do not select the current PCP by frequency.
• Identity-only: NPI/NPPES, licensure records, payer provider directories, public practice websites, maps, addresses, and phone listings (SRC-CMS-NPI-FACT-SHEET; SRC-CMS-PROVIDER-DIRECTORY-API).

Potential Proxi work. With the required access and beneficiary authorization, pull candidate PCP data from payer, claims, EHR, HIE, and directory sources; retain each source and as-of date; normalize clinician, NPI, practice, and alias information; present the candidates for confirmation; record corrections; and route unresolved conflicts. Proxi must keep payer-assigned PCP, beneficiary-identified PCP, and observed treating providers as separate facts.

Human role. The beneficiary or properly authorized representative supplies or confirms the relationship after software presents the source-linked candidates. No Proxi human is needed for a clear authenticated confirmation. L1 Philippines support performs administrative candidate cleanup or manual office verification only when the shared exception is triggered. L2 enters only when the person requests human help or ambiguity, disagreement, distress, accessibility failure, a no-PCP relationship problem, or relationship-dependent coordination remains. Software applies the approved representative-authority and disclosure rule. Missing identity or office facts return to L1; missing preference, relationship, or permission facts return to L2. Only a complete verified fact pattern that exposes a genuine legal-authority question not answered by the approved rule routes to Healthcare Legal Counsel under O-021, while the affected act remains held.

Provisional clean-path Proxi human time. 0 Puerto Rico navigator minutes for a clear authenticated direct confirmation. Use the shared 13-minute Philippines administrative exception only when administrative PCP-identity or manual-contact resolution is triggered; add L2 only for the human-entry conditions above.

Completion evidence. Record the outcome; clinician and practice; NPI when available; as-of and confirmation dates; confirming person and their authority; sources considered; and the disposition of every conflicting PCP candidate. A confirmed no-PCP outcome is truthful completion of this fact-finding task but does not establish an outside-PCP duty.

What does not prove completion. A recent claim, payer assignment alone, prescribing clinician, hospital attending, directory result, old EHR field, practice address, unanswered outreach, or a model-generated “most likely PCP.”

Confirm whether the PCP is outside the GUIDE care team#

When. Complete immediately after the current PCP is confirmed and repeat when either the PCP identity or GUIDE care-team membership changes.

What and how much. Produce one determination: inside the GUIDE care team, outside the GUIDE care team, or not yet determined. Unknown does not default to inside or outside.

Data inputs.

• Direct: the confirmed PCP identity and the Participant's authoritative current GUIDE practitioner roster or authenticated Participant confirmation of team membership.
• Corroborating: EHR care-team designations, Participant scheduling records, enrollment documentation, and organizational affiliation.
• Identity-only: NPI/NPPES, licensure, public or payer directories, practice address, group affiliation, and claims. These may improve identity matching but do not establish GUIDE-team membership.

Potential Proxi work. Normalize the PCP and roster identities; compare unique identifiers; identify aliases, practice changes, and same-name/different-provider cases; record the roster's effective date; and repeat the comparison after an authoritative PCP or roster change.

Human role. No Proxi human is needed for an exact unique-identifier match against an authoritative current roster. L1 resolves missing identifiers or ambiguous identity facts. If the authoritative GUIDE roster itself is stale, missing, or disputed, clean L1 identity work may continue but the membership determination remains blocked under O-PA-001 until the Participant-retained roster authority and correction act are named. L2 enters only if the resulting beneficiary relationship or preference question meets a D-021 entry condition.

Provisional clean-path Proxi human time. 0 minutes. Use the shared 13-minute Philippines administrative exception only when manual roster or identity resolution is triggered.

Completion evidence. Record the PCP identifier, authoritative roster source and effective date, match result, and the source and disposition of any human resolution.

What does not prove completion. Failure to find a name, a different address or organization, absence from an EHR screen, a claim from outside the Participant, or comparison against a stale or incomplete roster.

Confirm participation and communication preferences#

When. Complete during the first coordination interaction; before using a new channel or involving a caregiver or representative; and whenever preference, capacity, authority, language, accessibility, safety, or contact information changes.

What and how much. Create one current participation profile covering how the beneficiary wants to participate; preferred and fallback channels; language and accessible format; safe contact times and voicemail or message restrictions; who the beneficiary wants included and for what purpose; and explicit do-not-contact or disclosure restrictions. Preference and legal disclosure authority remain separate: asking to include a daughter records a preference but does not by itself settle the permission basis under O-021.

Data inputs.

• Direct: current choices expressed by the beneficiary; choices made by a representative acting within established authority; current communication restrictions; and applicable authorization or representation records.
• Corroborating: prior successful communication, care-plan preferences, documented language and accessibility needs, and prior navigator notes.
• Identity-only: emergency-contact fields, caregiver lists, portal-proxy records, payer contact records, phone numbers, and email addresses. These identify a possible contact but do not establish current preference or disclosure authority.

Potential Proxi work. Conduct an accessible text, voice, or portal interview; explain each option in plain language; read the resulting profile back; accept corrections; retain the source and date; apply explicit channel restrictions; send missing administrative facts to L1 and preference, relationship, or permission facts to L2; and re-evaluate the approved rule after correction. Proxi does not decide capacity or legal authority. A complete verified fact pattern that the approved rule does not cover holds only the affected act; only a genuine unresolved legal-authority question routes to Healthcare Legal Counsel.

Human role. The beneficiary or properly authorized representative makes the choices directly after software presents the current profile for confirmation. No Proxi human is needed on a clear accessible path. L1 Philippines support may perform bounded contact cleanup under the shared administrative exception. L2 enters only for a required/requested human conversation, inaccessible automation, ambiguity, conflicting wishes, distress, family disagreement, or relationship-dependent clarification. Software applies the approved identity, permission, recipient, purpose, content, channel, and restriction rule. Missing facts return to L1 or L2 according to the fact; only a complete verified fact pattern that exposes a genuine unresolved legal-authority question routes to Healthcare Legal Counsel. Possible decision-specific capacity questions route directly to the authorized clinician or Healthcare Legal Counsel rather than through L2.

Provisional clean-path Proxi human time. 0 Puerto Rico navigator minutes. Use the shared 13-minute Philippines administrative exception only for bounded manual contact cleanup; add navigator or clinical time only when its specific entry condition occurs. Healthcare Legal Counsel time is event-driven only for a genuine uncovered legal-authority question, not for routine disclosure-rule application.

Completion evidence. Record the current participation profile; who supplied it and their authority when applicable; confirmation date; communication and disclosure restrictions; accessibility needs; and any unresolved authority issue as a separate open matter.

What does not prove completion. Prior message delivery, silence or lack of objection, a caregiver possessing the phone, an emergency-contact designation, portal access, an old preference, or payer demographics.

Verify PCP routing information#

When. Complete after PCP and practice identity are confirmed and before the first GUIDE notice or care-plan release. Reopen after failed delivery or whenever the practice, department, endpoint, accepted document type, or channel changes.

What and how much. Verify at least one accepted route for the GUIDE participation notice and at least one route capable of providing meaningful access to the current care plan. The same endpoint may satisfy both only when the practice confirms that it accepts both content types.

Data inputs.

• Direct: authenticated confirmation from the receiving practice or records department identifying the exact department, endpoint, channel, and accepted document type; or a current practice-managed clinical-routing record.
• Corroborating: Participant EHR directories, HIE or Direct directories, payer Provider Directory API results, recent referral responses, and prior successful exchanges (SRC-CMS-PROVIDER-DIRECTORY-API). These are candidates for verification, not proof that the current endpoint accepts this packet.
• Identity-only: NPPES addresses and phone numbers, claims billing addresses, public websites, general switchboards, search results, and commercial fax listings (SRC-CMS-NPI-FACT-SHEET).

Potential Proxi work. Aggregate and normalize candidate phone, fax, electronic, and mailing endpoints; compare sources and dates; detect conflicts, changed destinations, and bounces; present the selected route for verification; retain the verification response; and reopen the task after delivery failure. Packet authorization and release remain separate work under O-021.

Human role. No Proxi human is needed when an authenticated current practice-managed route exists and matches the confirmed PCP and content type. L1 records/coordination support verifies uncertain routes with the practice and resolves discrepancies. Software separately applies the approved recipient, purpose, content, channel, permission, and restriction rule. Endpoint verification does not authorize disclosure. For a D-033 clean provider class, the accepted O-021 rule authorizes the send with no extra release human; otherwise retain the class-specific hold and any actually required reviewer. Only a genuine uncovered legal-authority question routes to Healthcare Legal Counsel.

Provisional clean-path Proxi human time. 0 minutes. Use the shared 13-minute Philippines administrative exception only when manual endpoint resolution is triggered. The clean-path result excludes any genuinely required individual review and any D-031 manual transport; neither is a universal per-packet floor.

Completion evidence. Record the matched PCP and practice, receiving department, endpoint and channel, accepted content type, verification source, named confirming party when applicable, verification date, and fallback route.

What does not prove completion. A valid-looking fax number, fax transmission success, absence of an electronic bounce, prior use of the endpoint, a general office number, claims address, or directory listing. Routing verification also does not prove that the GUIDE notice was delivered or that the PCP obtained meaningful access to the current care plan.

Outside-PCP exchange — detailed task cards#

The following eleven cards continue the four foundation cards above. They separate preparation, release, transport, receipt or meaningful access, response, clinical review, explanation, and downstream return because none proves another. The minute bands are provisional Proxi workload-calibration assumptions—low / typical / high minutes of actual Proxi human labor when that act is triggered. They exclude software time, beneficiary or caregiver time, outside-practice time, and labor already counted in another card. They are not CMS service clocks or field observations.

Identify the outside-PCP obligation#

When. After the current PCP and outside-team status are confirmed, and whenever an Assessment, Care Plan revision, transition, medication question, 24/7 contact, Ongoing contact, or other supported event may require the outside PCP to receive information or return an action.

Task and person value. Determine which obligations actually exist now: GUIDE participation notice, current-plan access, revised-plan access, a need-specific request, or more than one. The standing notice and plan-access duties do not create a monthly PCP call. If notice is complete, the PCP has meaningful access to the current approved plan, no revision exists, and no actual coordination need exists, record that no new PCP action is due.

Decisive facts. Confirmed outside PCP; notice status; current approved Care Plan reference; last plan made meaningfully accessible; later approved revisions; exact triggering concern and requested result; duplicate or already-open obligations; beneficiary communication and disclosure restrictions.

Potential Proxi work. Detect supported triggers; compare the current approved plan with the last plan made accessible; de-duplicate open work; preserve each obligation separately; and display why each obligation exists. AI may summarize the source event but may not invent a clinical question or decide whether a clinical concern is material.

Human role and provisional time. Clean rule application is software-only: 0 minutes. L1 enters at 3 / 6 / 12 minutes only to resolve a disconnected or conflicting administrative fact. L2 enters at 0 / 5 / 12 minutes only for a requested or relationship-dependent preference, participation, or communication exception. A clinical question routes directly to the exact authorized L3 or L4 professional; it does not pass through a generic navigator review.

Completion evidence. Every applicable obligation and its source, date, exact content or question, due condition, duplicate linkage, and next task; or a supported no-new-action result with the next event that would reopen work.

Not completion. “Outside PCP” by itself, passage of a month, an open Care Plan, or a navigator work-list entry.

Notify the outside PCP of GUIDE participation#

When. Once per applicable participation episode after the outside PCP, verified notice endpoint, exact approved notice content, recipient, purpose, channel, permission basis, and restrictions are established; repeat only after a supported correction, failed release, or materially changed participation fact requires it.

Task and person value. Give the current outside PCP the required GUIDE participation notice without disclosing unrelated information or asking the beneficiary to endure an unnecessary call.

Potential Proxi work. Populate the approved notice; bind it to the verified practice endpoint and exact beneficiary; run the approved recipient, purpose, content, channel, permission, and restriction rule; prevent duplicate release; preserve a human-readable release preview; and record technical delivery evidence.

Human role and provisional time. L1 packet preparation is 0 / 4 / 10 minutes when an administrative exception is triggered. L2 is 0 / 5 / 12 minutes only for actual relationship or permission clarification. When the exact notice is accepted as D-033 routine provider information and every sharing condition is valid, software sends with 0 extra human release minutes. O-021 still must approve that class and any genuinely required individual review; its 1 / 2 / 4 minutes apply only to that actual separate human act, not every notice. Unaccepted authority holds only the affected send.

Completion evidence. Exact notice, recipient/endpoint, purpose, accepted O-021/D-033 sharing-rule result, evidence of any genuinely required human review, send time, delivery result and correction/re-send linkage.

Not completion. A prepared draft, a queued transmission, technical success without the approved release, notice to the wrong practice, or an undocumented phone attempt.

Give the outside PCP meaningful access to the current Care Plan#

When. After the current Care Plan is approved and before claiming the standing outside-PCP duty complete; reopen after a failed route, access failure, plan replacement, recipient change, or disclosure restriction change.

Task and person value. Make the exact current approved Care Plan usefully available to the verified PCP. This is the same Care Plan artifact and release event used by Care Plan Task 47; do not manufacture a second plan or duplicate human labor.

Potential Proxi work. Retrieve only the current approved plan; prevent release of a draft or superseded plan; apply the approved disclosure rule; prepare the permitted packet or access grant; track delivery, portal activation, retrieval, rejection, and expiry; and reopen failed access.

Human role and provisional time. L1 preparation is 0 / 4 / 10 minutes when needed; L1 access repair is 3 / 8 / 20 minutes when a verified route fails. L2 is 0 / 5 / 12 minutes only for relationship, accessibility, or preference exceptions. The V1 release remains blocked under O-021; the provisional release placeholder is 1 / 2 / 4 minutes only after an actual performer is approved.

Completion evidence. Current approved plan identity and approval date; exact recipient, purpose, content, channel, permission basis, and restrictions; releasing human after O-021; delivery; and affirmative meaningful-access evidence appropriate to the channel.

Not completion. A portal invitation, fax success, email send, dormant account, unverified endpoint, old plan, or recipient acknowledgement that does not establish access to the exact current plan.

Send an approved revised Care Plan#

When. Every time the Care Plan SOP produces an approved revision that changes what the outside PCP must be able to access. A draft, proposed change, imported clinical note, or unchanged review does not trigger release.

Task and person value. Replace or supplement the prior accessible plan with the exact approved revision and make clear which plan is current.

Potential Proxi work. Detect an approved revision; link it to the prior accessible plan; prepare the permitted delta and/or full current plan according to approved policy; block drafts; apply the disclosure rule; and track delivery and access without recalling facts already proved.

Human role and provisional time. L1 preparation is 0 / 4 / 10 minutes; failed-access repair is 3 / 8 / 20 minutes only when triggered; L2 is 0 / 5 / 12 minutes for a named relationship or accessibility exception. The V1 release act remains blocked under O-021, with 1 / 2 / 4 minutes retained only as a post-decision calibration placeholder.

Completion evidence. Approved revision and prior-plan linkage, recipient and verified endpoint, disclosure-rule result, named release after O-021, delivery, meaningful access, and explicit current-plan status.

Not completion. Detecting a revision, drafting a packet, overwriting the old plan without an audit link, or sending a revision the PCP cannot retrieve.

Request needed information or input from the outside PCP#

When. Only when a supported coordination need requires a specific PCP fact, record, recommendation, action, or decision. Do not send a generic “please update us” request merely to create monthly activity.

Task and person value. Ask the smallest useful question, explain why the answer matters to the beneficiary, and request the exact return artifact or action needed for the affected GUIDE work.

Decisive facts. Trigger and desired result; already-known facts and contradictions; exact requested item; why the PCP is the appropriate source or authority; clinically assigned urgency when applicable; approved content; return route; and response evaluator.

Potential Proxi work. Reuse source-linked Assessment, Care Plan, Ongoing, Medication, transition, 24/7, and referral facts; draft a focused nonclinical request; assemble the smallest approved packet under applicable disclosure and Proxi data-minimization policy; expose conflicts and missing data; apply the disclosure rule; and track the request/response link. AI may draft a question but may not decide clinical necessity, urgency, or medical meaning.

Human role and provisional time. L1 performs administrative preparation or endpoint repair at 0 / 4 / 10 minutes. L2 formulates or confirms a genuinely relationship-dependent nonclinical request at 0 / 5 / 12 minutes. When the request requires clinical meaning, an L3 RN or behavioral professional performs the exact within-scope act at 5 / 10 / 20 minutes, or an L4 E/M/prescribing clinician performs the exact medical act at 8 / 15 / 30 minutes; do not add both unless two distinct protected acts are actually required. D-033's approved-rule clean send adds 0 human release minutes. The 1 / 2 / 4 minute placeholder applies only to a genuinely required, actually assigned separate human review; it is not a per-packet floor. O-021 still must establish the accepted class and any restricted-case authority.

After authorization, when manual sending is needed. Under D-031, Philippine L1 checks the exact approved packet/destination match, uses the permitted channel, sends without changing the question or clinical content, and records actual delivery/failure and factual receipt follow-up. The accepted D-033 rule supplies clean-path authorization; any actually required individual review is completed first. Count transmission once within the existing L1 administrative episode; the 0/4/10 band is a planning reference, not a free extra allowance or time cap. A sent request does not prove a PCP decision, clinical agreement or completion of the care need. The courier does not resolve missing sharing/class authority.

Completion evidence. Attributable need; exact question/item; author or confirming clinician when clinical; source-linked packet; recipient, purpose, content, channel, lawful basis and restrictions; accepted class-rule authorization and any actually required human review under O-021; send/delivery evidence; requested response; response evaluator; and due condition.

Not completion. A broad record dump, an AI-invented clinical question, release without authority, a sent request without delivery evidence, or an appointment that does not return the requested result.

Track the outside-PCP response#

When. After an authorized notice, plan-access act, or focused request creates a specific expected delivery, access, response, or correction result.

Task and person value. Quietly monitor the real obligation and contact the practice only when the result, due condition, failure, or clinically assigned timing supports action.

Potential Proxi work. Match acknowledgements, portal events, messages, documents, and calls to the exact outbound obligation; distinguish technical delivery, meaningful access, response, and clinical sufficiency; suppress duplicate reminders; and surface only the exact missing result. Exact retry counts and clocks remain open under O-019/O-020/O-004.

Human role and provisional time. Routine tracking is software-only: 0 minutes. L1 performs a permitted administrative pursuit at 3 / 8 / 20 minutes only after a configured due condition or failure. L2 is not the default tracker and enters only for a named relationship exception. A new clinical statement or urgent concern bypasses ordinary tracking to the correct clinical or emergency route.

Completion evidence. Obligation identity, expected result, due condition, every matched event and attempt, current result, remaining gap, and next permitted action.

Not completion. Calendar passage, an unmatched fax, generic voicemail, repeated contact with no approved retry basis, or a document that has not been matched to the correct person and request.

Resolve failed delivery or nonresponse#

When. When the verified notice, plan-access, or focused-request route fails; the recipient rejects the packet; meaningful access is absent; a response is overdue under approved policy; or the practice identifies a corrected route.

Task and person value. Repair only the failed transport or administrative fact while preserving the exact content and authority already approved. Do not turn nonresponse into a clinical answer.

Potential Proxi work. Expose the failure reason and prior attempts; compare verified alternate endpoints; prepare an unchanged resend when permitted; prevent unapproved content changes; and retain the original and corrected route. Software must re-evaluate recipient, purpose, content, channel, permission, and restrictions before any resend.

Human role and provisional time. L1 verifies the corrected endpoint or calls the practice at 3 / 8 / 20 minutes. L2 enters at 0 / 5 / 12 minutes only if beneficiary relationship or participation is genuinely needed. After the rule is re-evaluated, an unchanged resend in a D-033 covered provider class executes automatically when the accepted O-021 rule still matches. Care Plan and other classes retain their own release requirements. The existing 1 / 2 / 4 minute band applies only to a genuinely required, actually assigned separate human review. A clinical refusal or request for medical clarification routes to the exact authorized clinician, not through L1 or L2 interpretation.

Completion evidence. Failure type, failed endpoint, source of corrected routing, attempts, unchanged versus changed content, repeated class-rule authorization, evidence of any genuinely required reviewer, new delivery/access result, or truthful non-success with risk, continuing owner, and next plan.

Not completion. Blind resend, switching channels or recipients without reauthorization, exhausting an invented retry count, or marking a refused request complete.

Route returned information without interpreting it#

When. When the PCP returns a message, record, correction, refusal, recommendation, order, question, or other response.

Task and person value. Attach the return to the correct beneficiary and obligation, preserve the outside source, and place it directly with the person whose scope covers the response. Receipt never means clinical acceptance.

Potential Proxi work. Authenticate and match the source, person, request, encounter, and document; retain the original; extract a source-faithful index; identify missing pages, signatures, mismatches, and contradictions; quarantine wrong-person material; and route by the actual question. AI may summarize but the reviewer can always open the source.

Human role and provisional time. Clean matching and routing are software-only: 0 minutes. L1 repairs an administrative mismatch or incomplete transmission at 0 / 3 / 8 minutes. L1 and L2 do not interpret clinical content. The response goes directly to L3 RN for an exact nursing/function/transition/safety question, L3 behavioral for an exact behavioral/psychosocial/safeguarding question, or L4 for diagnosis, treatment, medication, prescribing, or other higher-authority medical judgment.

Completion evidence. Authenticated source, matched person and outbound obligation, document/response identity, original artifact, extraction provenance, defect status, exact receiving professional or nonclinical task, acceptance, and review due condition.

Not completion. Inbox receipt, OCR text alone, a model summary, routing to a generic clinician pool, or assuming the newest note supersedes conflicting sources.

Review clinically material returned information#

When. When the returned information contains a clinical finding, recommendation, order, symptom, functional or behavioral change, safety issue, medication matter, conflict, or question whose meaning affects care. Purely administrative confirmations do not require clinical blessing.

Task and person value. Determine what the source means for this beneficiary, what is accepted or remains disputed, and whether the current clinical or Care Plan content changes. The clinician receives a prepared packet and executes judgment rather than gathering routine records.

Potential Proxi work. Build a concise source-linked review packet; compare the return literally with the current Care Plan, reconciled medication result, prior clinician positions, goals, and open work; highlight differences and missing facts; and preserve original records. AI may prepare and propose questions but does not determine clinical materiality, urgency, acceptance, treatment, or plan effect.

Human role and provisional time. An L3 RN performs the exact within-scope nursing/function/transition/safety review at 5 / 10 / 20 minutes; an L3 behavioral professional performs the exact behavioral/psychosocial/safeguarding review at the same provisional band; an L4 clinician performs diagnosis, treatment, medication, prescribing, or higher-authority medical judgment at 8 / 15 / 30 minutes. Choose the narrowest qualified performer; do not automatically add RN, L2, and L4 review to the same prepared result. The outside PCP retains authority for the PCP's own source, recommendation, order, and treatment.

Completion evidence. Actual reviewer and beneficiary-location authority; exact question; sources reviewed; accepted, rejected, conflicting, or uncertain findings; rationale; clinical/Care Plan effect; urgency and safeguards; resulting actions; and remaining external or clinical dependency.

Not completion. A reviewer name without an act, an administrative “looks complete” check, a summary, receipt, recency, or unexplained concurrence.

Explain the resulting actions to the beneficiary or permitted caregiver#

When. After an authorized clinical or nonclinical coordination result exists and before claiming that the person received a useful return. Explain earlier when the approved result itself requires immediate communication.

Task and person value. Tell the person what was learned, what changes or remains unchanged, what they need to do, what Proxi or the outside practice will do, what remains unknown, and how to raise a question—using the person's preferred accessible modality.

Potential Proxi work. Generate a plain-language rendering of the approved result; bind it to the correct version and recipient; preserve disclosure restrictions; support text, voice, video, interpretation, read-back, and question capture; and route new clinical questions back without improvising an answer.

Human role and provisional time. Faithful delivery of an already authorized explanation has 0 new clinical minutes when the approved accessible route suffices. An actual individualized medical question, uncertainty or clinical counseling duty goes to the authoring L3 or L4 professional at 3 / 7 / 15 minutes if it is a separate act; count 0 additional minutes when already performed in the review encounter. L2 provides nonclinical coordination, accessibility recovery or relationship support at 0 / 5 / 12 minutes only when triggered. L2 does not add new clinical meaning.

Completion evidence. Recipient and participation authority; actual performer; approved content/version; modality and accommodations; questions and corrections; demonstrated understanding or documented limitation; remaining uncertainty; and next action.

Not completion. Message sent, voicemail left, generic education, navigator paraphrase of an unreviewed clinical result, or silence interpreted as understanding.

Carry the outside-PCP result into ongoing care#

When. After delivery/access, response, clinical review, or explanation produces an actual result or a truthful unresolved dependency that affects another GUIDE task.

Task and person value. Return the result only to the affected work so the beneficiary is not asked to repeat the story and one useful conversation can support several services without duplicate labor or false completion.

Potential Proxi work. Return provider identity or material baseline change to the affected Comprehensive Assessment task; return accepted choices, outside responses, responsibilities, revisions, distribution, and unresolved follow-up to the exact Care Plan tasks; return an actual promised result to Ongoing Tasks 34–35; return medication facts to M01/M07 and only the supported M10–M16 work; and open Referral Tasks 1–2 only when a separate community-service need exists. Software links shared preparation and human acts once.

Human role and provisional time. Clean source-linked return and task opening are software-only: 0 minutes. L2 performs a needed beneficiary-facing coordination return at 0 / 4 / 10 minutes only when a useful human touchpoint or relationship exception exists. A new protected question routes to the exact authorized clinician and is counted in its owning clinical task, not again here.

Completion evidence. Exact returned fact/result and source; sending and receiving task IDs; recipient acceptance and first required step where applicable; Care Plan effect or reviewed-no-change conclusion; person communication status; every remaining dependency and owner; and one labor record linked to all genuinely supported services.

Not completion. Updating every pillar, copying notes without a supported dependency, assigning a generic owner, treating task acceptance as service completion, or duplicating minutes across Care Coordination, Care Plan, Ongoing, Assessment, Medication, or Referral.

Procedure B — specialist or other clinical-provider referral#

1. Prepare the referral-decision packet. L0/L1 retrieves and organizes the reported need, relevant current records, prior referrals/results, contradictions, current location, coverage and access facts, and a draft clinical question. Software presents known location, language, accessibility, modality, schedule, transportation, caregiver, and other constraints for direct beneficiary/caregiver confirmation rather than asking a navigator to gather them again.
2. Establish the clinical branch and practical choice. Reuse a current attributable clinician-authored referral basis when it already covers this episode and question. A new, disputed, incomplete, outdated or changed clinical question goes directly to the exact qualified professional for necessity, urgency, provider requirements and expected return. RFA §5.2 permits this branch; it is not mandatory for every beneficiary. Software/L1 verifies factual options. The beneficiary may choose directly; L2 enters only for requested help, ambiguity, disagreement, distress, accessibility failure, warm introduction or relationship-dependent practical fit. Clinical suitability stays with the qualified professional.
3. Identify the PCP obligations. Determine the current PCP and whether active co-management exists. Unknown is not no. Prepare the required PCP referral notice and, when the PCP is actively co-managing, the clinically appropriate consultation.
4. Obtain any lawful order or authorization. The authorized clinician creates any required referral order. L0/L1 handles coverage and administrative documentation without creating clinical content.
5. Prepare the referral packet for authorized release. Include the exact clinical question, pertinent source-linked facts, relevant care-plan content, requested response, and return route. Optional notice to the specialist and optional care-plan sharing remain distinct from mandatory PCP notice.
6. Complete a requested introduction. When requested by the beneficiary or GUIDE caregiver, an approved care-team member makes a human-authored introduction to the new provider through the approved modality after the separate disclosure basis and exact content are confirmed. This is distinct from transmitting the referral and need not be a synchronous three-way call unless policy requires it.
7. Support access. Schedule, address practical barriers, and confirm the disposition. An appointment date is not an encounter, and an encounter claim is not correctly matched clinical documentation.
8. Retrieve the result. After an encounter, obtain the correctly matched visit documentation and any recommendations or changes. Partial, illegible, wrong-patient, wrong-encounter, unsigned, or internally inconsistent material does not satisfy the return obligation.
9. Reconcile the clinical result. The authorized professional interprets the returned recommendation and its effect on the current plan, medication regimen, PCP position, goals and circumstances. A matched already-reviewed result is reused; factual receipt does not trigger a second identical clinical act. Conflicting instructions remain held for proper clinical disposition.
10. Explain and execute the next plan. Deliver the approved result accessibly; the clinician supplies individualized clinical meaning when needed, and L2 supplies only triggered nonclinical support. Software carries approved actions to their established tasks; L1 handles disconnected logistics. Do not count future tests, dispensing, treatment or community services as complete from referral-loop review or owner acceptance.
11. Close truthfully. Apply the successful or non-success criteria below. Referral rejection, scheduling, a safety handoff, or exhausted administrative attempts do not by themselves establish successful closed-loop completion.

Procedure C — transition between residence and a care setting#

1. Classify the transition factually. Confirm the from/to settings, unit or level of care when known, transition direction, event and awareness dates, current location, expected duration, and whether another transition is planned. Do not infer RCC, memory-care, hospice-benefit, or long-term-nursing status from a facility name.
2. Begin support even when records are missing. Missing discharge information is not evidence of no change. L0/L1 immediately pursues and organizes available records, prior instructions, known supports, missing items, and candidate current needs. An urgent or required live-human route begins immediately while preparation continues in parallel.
3. Confirm only what sources cannot establish. Present the prepared transition facts to the beneficiary or permitted caregiver and ask them to confirm, correct, and supply what happened, what they understand, current lived needs/supports, and how they want Proxi to help. L2 joins only for a required/requested human recovery conversation, ambiguity, distress, disagreement, accessibility failure, or relationship-dependent barrier. For discharge home, the proposed Proxi target is a recovery contact within 48 to 72 hours, informed by AHRQ RED; this is not a CMS deadline and remains subject to O-004.
4. Obtain the transition packet. Seek the discharge or transfer summary, instructions, medication lists and orders, diagnoses as documented by the treating source, pending tests and results, follow-up appointments, warning signs supplied by clinicians, equipment, home-service orders, dietary or activity instructions when material, and responsible contacts.
5. Perform clinical and psychosocial review when triggered. Software/L1 builds the structured source-faithful transition report from records and direct beneficiary/caregiver statements, preserving missing and conflicting facts. The prepared packet routes directly to L3 when symptoms, change from baseline, safety concerns, medication discrepancy, psychosocial or safeguarding concern, unreliable information, or a clinically designated high-risk transition is present. L4/L5 enters for medical decisions. L2 is not a clinical gateway and supplies only genuinely needed relationship context. Routine stable transitions do not require automatic licensed review unless Proxi explicitly adopts that broader clinical-service design.
6. Complete the linked medication work. Compare pre-transition regimen, facility administration, discharge orders, pharmacy events, household supply, and reported current use. Merely opening the Medication Management case is insufficient; the route-specific authorized clinician must produce the applicable reconciliation outcome.
7. Assign every pending clinical result. Record each pending test, laboratory result, imaging result, pathology result, specialist recommendation, or other unresolved clinical item; name who will obtain it, who is clinically responsible for reviewing it, how the result returns, and what happens if it does not arrive.
8. Make follow-up executable. Confirm the purpose, responsible clinician, date or scheduling need, location, modality, transport, interpretation, accessibility, and required records for each follow-up visit or test.
9. Confirm equipment, services, and basic supports. Verify delivery and usability of ordered equipment and home services and address food, transportation, personal care, housing, caregiver, and other practical needs through the appropriate Proxi service.
10. Obtain higher-authority clinical disposition. L4 or the applicable treating clinician resolves new symptoms, conflicting instructions, unclear treatment ownership, clinical deterioration, medication decisions, or a need to alter the medical plan.
11. Communicate with teach-back. Provide an accessible, clinician-approved recovery summary covering the current plan, medication instructions, follow-up, pending results, equipment and services, and the approved route for problems. Ask the beneficiary or permitted caregiver to explain the plan back in their own words; re-explain and add support when understanding remains incomplete.
12. Follow through. Confirm medication access and reported implementation, appointments, results, equipment, home services, caregiver availability, and whether new problems or another transition occurred. A new transition starts linked work without erasing the prior episode.
13. Reconcile the care plan. Update current setting, providers, responsibilities, services, goals, and accepted clinical recommendations, or record an authorized reviewed-no-change conclusion.
14. Close only when the transition criteria below are met. A clinically safe provisional plan may allow immediate care to continue, but it does not prove that missing records, medication, results, equipment, services, or communication obligations are complete.

Procedure D — additional clinical coordination#

1. Define the unmet need, beneficiary's desired result, and whether the need is factual, practical, clinical, behavioral, privacy-related, or mixed.
2. Identify the person or organization with actual authority and practical ability to act; do not assign an external clinician unilaterally.
3. Obtain clinical definition and urgency from the appropriate licensed professional when needed.
4. Assemble and release a focused packet through the approved process, track the response, and route the returned content without interpreting it administratively.
5. Obtain the authorized disposition, explain it through the correct role, update the care plan when needed, and assign every resulting task.

Shared episode labor, release and completion#

All minute bands below are low / typical / high incremental Proxi-paid human minutes, provisional planning estimates rather than CMS minima or observed staffing. A clean software/direct-response path can be zero. A shared provider call, recovery conversation or clinical encounter is counted once across the tasks and pillars it actually serves; do not add every card's potential bands. Routine records, scheduling and form preparation stay outside the clinician's act. Beneficiary, caregiver, payer and outside-provider labor is separate.

For V1 Care Coordination PHI packets, O-021 must establish the content class, accepted rule, restrictions and retained evidence before release. D-033 clean routine authorized-provider requests/information add no release human; any genuinely required individual review uses its actually authorized performer. Clinical authorship, a verified endpoint and a prepared packet do not themselves authorize disclosure. Keep any real review separate from permitted preparation, direct choice and already approved emergency connection. Do not invent a privacy officer or unnamed Participant reviewer.

A professional product, the coordination episode outcome, and every downstream service result are separate. Missing evidence necessary for today's clinical judgment prevents a successful professional product; a future test with an accepted reviewer, timing, return route and safeguards does not erase one already completed. Handoff acceptance or scheduling proves only that milestone. Terminal/non-success rules remain draft under O-019/O-020/O-024; they are not approved merely because the cards describe them.

Specialist referral — detailed task cards#

Specialist referral — confirm the clinical need#

Trigger, purpose, and standing. Use when a source raises a physical or behavioral co-occurring-condition question. The RFA summary lists referral for co-occurring conditions as needed, while Appendix B §5.2 says the Participant may refer. This is a conditional needed-care branch, not a universal referral or a safely assumed elective add-on; final Participant interpretation remains O-020/O-PA-001. The product is an attributable clinical decision about appropriateness, urgency, provider type, question, and expected return—not an appointment.

Decisive facts. Source-linked concern, change from baseline, location, diagnoses, prior workup/referrals/results, treating clinicians, goals, relevant medications, contradictions, and prior clinician-authored referral basis with date/scope. Nonexhaustive clinician-defined examples include neurology for a movement disorder, cardiology for syncope, or behavioral health for depression. A current authorized basis may satisfy the protected act; age alone does not make it current.

Procedure.

1. L0/Philippine L1 assemble originals, literal reports, conflicts, and exact question; urgent cues invoke the safety interrupt.
2. Reuse a current authorized clinician-authored basis when it still covers the condition, urgency, specialty, and circumstances.
3. Otherwise the beneficiary-location-authorized U.S. behavioral clinician (L3) professional decides a within-scope behavioral referral question, or U.S. medical clinician (L4)/treating clinician decides medical necessity, urgency, provider type, and requested return.
4. Record refer, do not refer, or insufficient basis, with current safe course and missing evidence.

Automation, people, and minutes. Preparation is software; Philippine L1 0 / 4 / 10 for disconnected administrative sources. A separate U.S. behavioral clinician (L3) act is 5 / 10 / 20 or U.S. medical clinician (L4) medical act 8 / 15 / 30; use 0 incremental when already produced in the same current clinical encounter. Puerto Rico L2 enters only for a separate D-021 relationship need at 0 / 5 / 12.

Completion/failure and return. Complete with attributable clinical disposition, authority/location, rationale, urgency, specialty/question, expected result, and next route. Missing authority or prerequisite facts returns the exact gap to its owner; immediate risk proceeds independently. Return the decision to explanation, provider-choice, order/coverage, and PCP-obligation tasks. A directory match, beneficiary request, AI recommendation, or scheduled visit is not completion.

Specialist referral — explain the purpose#

Trigger, purpose, and standing. After a valid referral basis exists and before choice or attendance. This is Proxi/AHRQ referral-usability design in the §5.2 route, not an express standalone CMS live-explanation duty. Explain why the referral is considered and what the receiving clinician should address without creating another review.

Decisive facts. Current clinician-authored rationale; specialty/question; urgency; limits; known alternatives; expected records/tests; current instruction while waiting; language and accessibility; permitted caregiver participation; and uncertainty. Reuse an approved explanation only while its basis and circumstances remain current.

Procedure.

1. L0 renders the approved rationale accessibly and flags language lacking an approved explanation.
2. Deliver digitally or in the approved modality; record corrections/questions.
3. Return a new prognosis, treatment, urgency, or interpretive question to the authorized clinician.
4. Puerto Rico L2 enters only for requested help, inaccessible modality, distress, disagreement, or relationship support.
5. Preserve refusal or uncertainty without converting it to consent or cancellation.

Automation, people, and minutes. Faithful accessible delivery and a clear direct acknowledgement are 0 human minutes. Puerto Rico L2 support is 0 / 5 / 12. The authoring L3/U.S. medical clinician (L4) clinician's separate individualized explanation is 3 / 7 / 15, or 0 incremental when given in the originating clinical encounter. Philippine L1 may correct contact facts at 0 / 3 / 8 but does not explain clinical rationale.

Completion/failure and return. Complete with rationale/version, recipient, modality, accommodations, questions/corrections, and stated understanding or limitation. Return interest, refusal, uncertainty, or new questions to choice/referral-basis work. Delivery, a generic specialty description, navigator paraphrase, or silence is not understanding. Missing, disputed, or outdated rationale returns to the clinician.

Specialist referral — gather beneficiary preferences and barriers#

Trigger, purpose, and standing. After the referral branch and clinical boundaries are established, and again when access circumstances change. This necessary §5.2-§5.3 work makes the referral usable while preserving beneficiary choice; it is not clinical screening.

Decisive facts. Direct beneficiary or decision-specific representative choices for clinician/practice, geography, travel distance, language, accessibility, modality, schedule, sex/gender preference if volunteered, caregiver attendance, transportation, technology, cost/coverage concerns, and willingness to wait. Distinguish preferences from hard constraints, unknowns, caregiver wishes, and representative authority. Existing source facts and prior confirmed preferences are presented with dates rather than recollected from scratch.

Procedure.

1. L0 prepopulates current, source-dated facts and asks the beneficiary/authorized representative to confirm, correct, skip, or add constraints through an accessible route.
2. Record each response with speaker and decision-specific authority; a caregiver may supply logistics without becoming the selector.
3. Philippine L1 verifies objective disconnected facts such as address, transport vendor, or plan contact only when needed.
4. Puerto Rico L2 conducts the focused human conversation only for requested help, ambiguity, disagreement, distress, accessibility failure, or relationship-dependent clarification.
5. New symptoms, urgency concerns, or clinical-suitability questions stop this task and route directly to the authorized clinician.

Automation, people, and minutes. Direct authenticated confirmation is 0 Proxi human minutes. Philippine L1 factual repair is 0 / 4 / 10. Puerto Rico L2 clarification is 0 / 6 / 15; do not add both unless they perform distinct acts. There is no routine clinician time.

Completion/failure and return. Complete with the attributable preference/constraint set, source/as-of date, speaker and authority, accommodations, unknowns, conflicts, and willingness for next steps. Return the exact constraints to candidate identification, availability, scheduling, and barrier tasks. An old preference, caregiver assumption, directory result, or completed questionnaire with unanswered material constraints is not completion. If the person declines to state a preference, preserve that choice and present otherwise suitable options without manufacturing one.

Specialist referral — identify candidate providers#

Trigger, purpose, and standing. After the clinician defines the provider type/question and the beneficiary confirms material constraints. This necessary delivery work identifies plausible choices; it does not select the provider or infer clinical capability from a directory label.

Decisive facts. Clinician-defined specialty/subspecialty and required service; beneficiary constraints; current payer/network data; provider name/NPI/practice; licensed specialty and status; service area; language/accessibility/modality claims; referral/order requirements; directory source and as-of date; prior treatment relationship; and known conflicts. SRC-CMS-PROVIDER-DIRECTORY-API and SRC-CMS-NPI-FACT-SHEET support candidate discovery/identity only, not current availability, credential sufficiency, treatment relationship, or usable endpoint.

Procedure.

1. L0 searches approved current sources and produces an unranked or transparently criteria-ranked candidate set tied to the exact clinical and practical constraints.
2. Exclude only on supported objective criteria; retain unknowns and disclose inventory scope.
3. Philippine L1 manually verifies stale or disconnected identity/network facts when the candidate cannot be resolved electronically.
4. If the required capability is clinically ambiguous—for example movement-disorder neurology versus general neurology—return only that narrow question to the authoring U.S. medical clinician (L4)/treating clinician or qualified U.S. behavioral clinician (L3) professional.
5. Present viable options and a truthful no-match result to the choice task.

Automation, people, and minutes. Connected candidate generation is 0 human minutes. Philippine L1 verification uses one shared provider-search episode of 0 / 7 / 20 across candidates. Puerto Rico L2 is 0 / 5 / 12 only for a D-021 preference/relationship exception. Separate clinical suitability clarification is 0 / 5 / 15 by the exact authorized professional, not an automatic second review.

Completion/failure and return. Complete with each candidate, matching criteria, source/as-of date, unverified fields, exclusions and reasons, plus no-match if applicable. Return the set to beneficiary choice and availability verification. A search result, NPI, payer listing, star rating, referral volume, or AI ranking alone is not a suitable-provider determination. Wrong-specialty, inactive, moved, stale, or no-safe-match cases follow CC-E01 without releasing PHI.

Specialist referral — support beneficiary choice#

Trigger, purpose, and standing. When at least one appropriately bounded candidate or a truthful no-match result is ready. Necessary delivery work under §5.2-§5.3 preserves freedom of choice; Proxi does not choose, steer through hidden sponsorship, or create a mandatory navigator validation of a clear choice.

Decisive facts. Candidate facts and unknowns; clinician-defined provider type; beneficiary priorities and hard constraints; network/cost uncertainty; prior relationship; wait estimates; material accessibility; inventory scope; and who has decision authority. Caregiver preference remains separate from a capable beneficiary's choice.

Procedure.

1. L0 presents comparable facts in plain language, identifies stale/unknown items, and explains why each candidate appeared without claiming clinical superiority.
2. The beneficiary or decision-specific authorized representative selects, requests more facts, declines, or asks for human help.
3. Record the attributable choice and confirm that it applies to this referral.
4. Puerto Rico L2 enters only for requested help, ambiguity, disagreement, distress, inaccessible automation, or relationship-sensitive tradeoffs; Puerto Rico L2 may clarify facts and values but may not choose.
5. A clinical-fit question returns directly to the authoring clinician; a coverage fact returns to Philippine L1/payer verification.

Automation, people, and minutes. A clear authenticated direct choice is 0 Proxi human minutes. Puerto Rico L2 choice support is 0 / 5 / 12. Philippine L1 objective fact repair is 0 / 4 / 10. A separate clinician clarification is 0 / 5 / 15 only if clinical suitability, not preference, is unresolved.

Completion/failure and return. Complete with selected provider or explicit decline/no-choice, speaker and authority, options presented, decisive preferences, known unknowns, requested human help, and next action. Return selection to availability/order/scheduling; return no-choice or refusal to the clinical-risk/alternative plan. A default, prechecked option, unexplained ranking, caregiver selection over a capable beneficiary, or navigator approval is not completion. If no candidate meets the constraints, record no match and preserve the referral need rather than declaring the referral closed.

Specialist referral — verify provider availability and fit#

Trigger, purpose, and standing. After selection or before presenting a candidate whose availability facts are materially uncertain. This necessary execution step establishes operational fit; it does not redo the clinician's referral decision or credential the specialist clinically.

Decisive facts. Exact service/question; provider/practice identity; current service offering; new-patient status; service area; appointment modality/location; accessibility and interpreter capability; scheduling horizon; coverage/network status and limitations; referral/order/document prerequisites; beneficiary constraints; verification source, speaker, and date. Directory claims are candidates, not current confirmation.

Procedure.

1. L0 compares current practice, payer, and scheduling sources against the beneficiary's constraints and flags disconnected facts.
2. If an authenticated current practice endpoint confirms all required operational facts, record fit with no human touch.
3. Philippine L1 contacts the office/payer only for dynamic or unavailable facts and captures responses verbatim.
4. Puerto Rico L2 enters only when the person requests human negotiation or a preference conflict remains.
5. If the office's service description leaves clinical capability uncertain, the exact qualified U.S. behavioral clinician (L3) or U.S. medical clinician (L4)/treating clinician resolves that narrow question; Philippine L1/Puerto Rico L2 do not infer it.
6. Unavailability/waitlist routes to CC-E05/CC-E06 and beneficiary choice.

Automation, people, and minutes. Clean verification is 0. Philippine L1 manual verification is 3 / 8 / 20. Puerto Rico L2 exception support is 0 / 5 / 12. Clinician fit clarification is 0 / 5 / 15, or 0 incremental if already part of the referral decision.

Completion/failure and return. Complete with verified operational facts, source/as-of date, matched constraints, remaining unknowns, and viable/not-viable/waitlist outcome. Return viable status to order/scheduling; return not viable to the choice task. A directory listing, phone number, payer badge, voicemail, appointment request, or presumed subspecialty is not confirmation. Changed or conflicting facts reopen only the affected verification.

Specialist referral — determine whether the PCP is actively co-managing#

Trigger, purpose, and standing. After the referral branch is chosen and before applying §5.2's conditional PCP-consultation language. This necessary factual task determines whether consultation is applicable; PCP notice remains separately required after referral regardless. Unknown is not no.

Decisive facts. Confirmed current PCP; recent PCP encounters and source dates; current orders/referrals; explicit responsibility or co-management statements; care-plan roles; beneficiary report; authenticated practice confirmation; current condition/specialty scope; and any transfer/termination. Claims prove utilization, not active responsibility. A current substantive PCP consultation already recorded for this same referral may prove both active involvement and consultation; do not manufacture a repeat.

Procedure.

1. L0 assembles source-separated evidence and identifies whether an explicit current co-management statement exists.
2. Present the prepared facts directly to the beneficiary/authorized representative for correction when the relationship is unclear.
3. Philippine L1 verifies only objective practice/relationship facts that remain disconnected.
4. Classify yes, no, or unknown using the approved O-020 evidence standard once settled; until then preserve the facts and hold only the applicability conclusion that depends on them.
5. If determining current clinical responsibility itself requires professional judgment, send the narrow question to the existing treating/U.S. medical clinician (L4) clinician, not Puerto Rico L2.

Automation, people, and minutes. Exact current evidence can yield 0 human minutes. Philippine L1 factual verification is 0 / 4 / 10. Puerto Rico L2 relationship clarification is 0 / 5 / 12 only under D-021. Clinician responsibility clarification is 0 / 5 / 15, with 0 incremental for an already documented current determination.

Completion/failure and return. Complete with yes/no/unknown, source/effective date, scope, and rationale; return yes to PCP consultation, all outcomes to mandatory PCP notice. A PCP name, recent claim, old referral, or portal listing is insufficient. Unknown or disputed evidence keeps consultation applicability unresolved under CC-E22; it does not block independent specialist access or urgent care unless the clinician says the referral itself depends on PCP input.

Specialist referral — consult the actively co-managing PCP#

Trigger, purpose, and standing. When current evidence establishes active PCP co-management and the referral is being made. RFA §5.2 says the referral should be made in consultation with that PCP. The useful result is attributable PCP input, not merely a sent message.

Decisive facts. Referral decision/urgency; clinical question; PCP identity and co-management scope; relevant Care Plan/condition/medication facts; prior consultation for this referral; endpoint; requested response; conflicts; restrictions; and delay risk. A current consultation already addressing the same referral/question may satisfy the act.

Procedure.

1. L0/Philippine L1 prepare the focused packet and unanswered question.
2. If a current attributable PCP response covers the same scope and no material fact changed, link it and proceed.
3. Otherwise reuse the current referral-basis author's exact rationale—including an authorized U.S. behavioral clinician (L3) or outside treating clinician—without demanding a new U.S. medical clinician (L4) act; the exact authorized clinician supplies any new protected question. Philippine L1 arranges/pursues contact; Puerto Rico L2 joins only for a distinct relationship need.
4. Preserve agreement, disagreement, modification, refusal, or nonresponse verbatim.
5. Clinical conflict returns to the authorized clinicians under CC-E12; nonresponse follows O-004/O-020 without an invented answer.

Automation, people, and minutes. Philippine L1 preparation/pursuit is 0 / 7 / 20. A separate Proxi U.S. behavioral clinician (L3) act is 0 / 5 / 15 or U.S. medical clinician (L4) medical act 0 / 8 / 20; use 0 incremental for reused current rationale or same-encounter work. Puerto Rico L2 is 0 / 5 / 12 only if separately triggered. Outside-clinician time is excluded.

Completion/failure and return. Complete with PCP identity, co-management basis, question, packet, modality/date, attributable response, clinical disposition, conflict, and referral effect. Return it to send/order/plan work. A sent message, receipt, staff acknowledgement, specialist receipt, or silence is not consultation. Until O-020/O-019 settle non-success dispositions, no failed/refused/nonresponsive consultation outcome is runnable. Urgent independent care may continue only under an authorized safe course.

Specialist referral — obtain required referral order or coverage information#

Trigger, purpose, and standing. After selection when the practice or payer requires an order, authorization, network confirmation, or supporting record. This is necessary delivery work, not a universal GUIDE order requirement or proof of specialist acceptance.

Decisive facts. Provider/service; referral basis; exact requirement/source; payer/plan facts; network/prior-authorization status; coverage/cost uncertainty; ordering authority; required clinical content; endpoint; due condition; and existing order/authorization. Keep order, authorization, estimate, and supporting records separate.

Procedure.

1. L0 retrieves requirements and reuses an order/authorization only when provider, service, scope, date, and beneficiary match.
2. Philippine L1 verifies dynamic requirements and assembles documents without inventing clinical content.
3. If a new order is required, the authorized ordering clinician authors/signs it; the clinician does not chase payer status.
4. Philippine L1 pursues authorization after the release gate and records responses verbatim.
5. Denial, changed service, or clinical-justification questions return to the ordering/treating clinician; coverage choices use direct-choice or triggered Puerto Rico L2 routes.

Automation, people, and minutes. Clean reuse/preparation is 0 human minutes. Philippine L1 administrative work is 0 / 8 / 20. A separate Proxi ordering-clinician act is 1 / 3 / 7, or 0 incremental when authored in the referral decision. Puerto Rico L2 is 0 / 5 / 12 for a genuine person-facing coverage exception. Outside payer/provider time is excluded.

Completion/failure and return. Complete with requirements, source/date, order author/authority, submitted item, authorization/coverage response, remaining condition, and next route. Return satisfied prerequisites to send/scheduling; return denial or missing basis to choice/clinical review. A draft, request, eligibility response, or undelivered order does not establish coverage, acceptance, appointment, encounter, or loop completion.

Specialist referral — send the referral#

Trigger, purpose, and standing. When the selected destination, clinician-authored basis/question, required order/authorization materials, disclosure facts, and accepted endpoint are ready. This necessary §5.2 work places the authorized request with the receiving provider; it is not the encounter or clinical result.

Decisive facts. Beneficiary and destination identity; verified department/endpoint; exact referral question and author; current order/authorization; minimum focused clinical facts; included attachments and versions; purpose; permission/restrictions; channel; requested response/return route; duplicate/in-flight referral check; and urgency assigned by the clinician. Optional GUIDE notice and optional care-plan content remain separately selected elements.

Procedure.

1. L0 populates one source-linked focused packet, excludes unrelated chart content, and compares it with open/previous referrals to prevent accidental duplication (CC-E16).
2. Philippine L1 corrects objective recipient, endpoint, attachment, or format defects and prepares a human-readable release preview.
3. Apply the approved disclosure rule; in V1, hold the release until O-021 names the canonical human and evidence.
4. After an approved release, transmit once through the accepted route and record technical delivery separately from receipt/acceptance.
5. Rejection, wrong patient/practice, changed destination, or resend opens the exact correction and a new release event; no blind reroute.

Automation, people, and minutes. Clean preparation is 0. Philippine L1 exception preparation is 0 / 4 / 10. The unresolved V1 release placeholder is 1 / 2 / 4 only after O-021; it is not runnable now. Puerto Rico L2 is 0 / 5 / 12 only for a separate relationship/permission issue. No new clinician review is required for unchanged current clinician-authored content.

Completion/failure and return. Complete this send task with packet identity/version, recipient/endpoint, rule result, named authorized releaser after O-021, release time, delivery result, and correction links. Return receipt/acceptance expectation to tracking and scheduling. A draft, queue entry, fax success, portal upload, or practice acknowledgement is not an encounter, returned documentation, clinical acceptance, PCP notice, or D-009 closure.

Specialist referral — notify the PCP#

Trigger, purpose, and standing. Every time a §5.2 referral is made, prepare and complete the required PCP notice. This public RFA duty is distinct from consultation with an actively co-managing PCP and from the specialist's receipt. It applies whether co-management is yes, no, or unresolved, once the referral itself has been made.

Decisive facts. Current PCP/practice; referral destination/type/date; clinician-supplied reason; authorized urgency/current-course content; notice version; endpoint; restrictions; permission basis; referral status; and changed-PCP/in-flight facts. Do not infer notice from specialist selection, EHR affiliation, or a copied note.

Procedure.

1. L0 creates the smallest approved notice and checks for an exact existing notice tied to this referral.
2. Philippine L1 verifies PCP identity and accepted endpoint and corrects only administrative fields.
3. Apply the approved disclosure rule. When this factual PCP notice is accepted as routine authorized-provider information under O-021/D-033, software sends it with no extra per-packet human OK; any genuinely required individual review occurs first.
4. After authorized release, track delivery/receipt separately.
5. A changed PCP before send invalidates the unsent destination; a change after send does not recall the packet and may create a separately authorized notice to the new PCP under CC-E20.
6. Failure remains a distinct obligation under CC-E22; it does not erase the specialist referral.

Automation, people, and minutes. Clean preparation/tracking and an accepted D-033 send add 0 human release minutes. Philippine L1 correction/pursuit is 0 / 4 / 10. The existing 1 / 2 / 4 band applies only to an actually required separate human review. Puerto Rico L2 is 0 / 5 / 12 only for a real relationship/permission question. No routine clinician or navigator blessing is added.

Completion/failure and return. Complete with matched referral, current PCP, exact notice, accepted class-rule authorization, evidence of any genuinely required review, delivery/receipt evidence required by approved policy, and any corrected destination. Return PCP questions to the appropriate clinical or administrative task. Specialist receipt, consultation, chart-copy, attempted call, or technical send alone does not satisfy the PCP-notice obligation.

Specialist referral — notify the new provider of GUIDE participation when useful#

Trigger, purpose, and standing. Consider after selection only when GUIDE notice has a concrete coordination purpose, such as clarifying the return route. RFA §5.2 permits but does not require it; do not hide it inside mandatory PCP notice.

Decisive facts. Provider identity; current purpose; approved text; return/contact route; restrictions; recipient/purpose/channel; prior notice; and segmented-content status. GUIDE notice alone does not authorize Care Plan or unrelated clinical sharing.

Procedure.

1. L0 applies approved conditions and records notify/no-notice with reason.
2. If useful, prepare factual GUIDE text as a distinct element without clinical claims.
3. Seek beneficiary clarification only for a missing preference; Puerto Rico L2 enters for requested relationship support.
4. Apply the disclosure rule. When the factual GUIDE notice is accepted as routine authorized-provider information under O-021/D-033, software sends it with no extra per-packet human OK; any genuinely required individual review occurs first.
5. After release, separate delivery from acceptance/future coordination.

Automation, people, and minutes. Supported no-notice, clean preparation and an accepted D-033 send add 0 human release minutes. Philippine L1 objective recipient correction is 0 / 3 / 8. Puerto Rico L2 is 0 / 5 / 12 only when the coordination purpose requires a person-facing relationship act. The existing 1 / 2 / 4 band applies only to an actually required separate human review. No clinician is needed for unchanged factual program text.

Completion/failure and return. Complete with applicable/not-applicable result, reason, text/version, recipient, accepted class-rule authorization, evidence of any genuinely required review, delivery evidence, or hold. Return provider questions to the correct owner. A packet mentioning GUIDE, referral receipt, or inferred EHR awareness is not proof and does not affect loop completion.

Specialist referral — provide relevant care-plan information#

Trigger, purpose, and standing. When current Care Plan content would materially help the receiving provider answer the clinician-defined referral question or support the visit. RFA §5.2 permits this sharing; it does not require a whole-plan dump for every referral. The task reuses the current approved plan artifact rather than manufacturing a referral-specific substitute.

Decisive facts. Approved Care Plan/version; referral question; relevant sections; destination/format; recipient/purpose/channel; restrictions/permission; segmented content; clinical source; prior accessible version; and existing sharing. Exclude draft, superseded, caregiver-confidential, or unrelated content.

Procedure.

1. L0 proposes the smallest relevant current-plan portion using approved selection rules and displays inclusions/exclusions in the release preview.
2. Philippine L1 verifies plan identity, destination, format, and attachment completeness.
3. If relevance of clinical content is genuinely uncertain, the authoring/authorized L3 or U.S. medical clinician (L4) clinician resolves only that selection question; do not send the whole plan to avoid judgment.
4. Apply disclosure/segmentation rules and hold V1 release until O-021 names the performer.
5. After release, track delivery and meaningful access separately; changed content creates a new exact packet/release event.

Automation, people, and minutes. Clean selection/preparation is 0. Philippine L1 exception work is 0 / 4 / 10. Clinical content selection is 0 / 3 / 7, or 0 incremental when already determined in the referral encounter. Puerto Rico L2 is 0 / 5 / 12 only for a separate person-facing issue. Release placeholder: 1 / 2 / 4 after O-021.

Completion/failure and return. Complete with approved plan/version, exact portion, rationale, recipient/purpose, authorized release, delivery/access evidence, and restrictions. Return access failure to endpoint repair without altering content. Referral packet receipt, portal invitation, fax success, obsolete plan, or clinician note is not meaningful access to the selected current content; optional plan sharing never substitutes for mandatory PCP notice or returned visit documentation.

Specialist referral — introduce the beneficiary when requested#

Trigger, purpose, and standing. When the beneficiary or verified GUIDE caregiver requests an introduction to a new provider. RFA §5.3 makes it a triggered public duty. It need not be live; an approved asynchronous human-authored introduction may satisfy the selected modality.

Decisive facts. Requester identity and verified beneficiary/GUIDE-caregiver status; capable beneficiary's wishes; new provider identity; requested modality/timing; approved care-team member; separate disclosure basis and exact content; relevant history/coordination purpose; return route; accessibility; provider acceptance/refusal; and any requester-beneficiary conflict. Caregiver requester eligibility does not automatically confer provider-selection or treatment authority (CC-E23).

Procedure.

1. L0 prepares the request, verified recipient, bounded history, return route, and modality; Philippine L1 may verify logistics but is not presumed an eligible introducer.
2. Resolve only missing requester/beneficiary preference facts; preserve a capable beneficiary's objection.
3. The approved care-team member authors and makes the introduction by the selected approved modality, identifies the care-team return route, and requests provider acknowledgement where applicable.
4. Record completed, withdrawn, beneficiary-conflict disposition, provider refusal, or explicit failed introduction with next plan.
5. A late request remains actionable even after the visit if it still has a useful coordination purpose.

Automation, people, and minutes. Preparation is 0 human minutes; Philippine L1 logistics are 0 / 3 / 8. The care-team human act is provisionally 5 / 10 / 20 after O-021 approves actor/modality/authority; until then the affected act is design-blocked. Outside provider participation is excluded. Do not also charge a default Puerto Rico L2 choice or release episode unless separately performed.

Completion/failure and return. Complete only with requester status, beneficiary position, performer/approved care-team authority, exact content, modality/time, provider result, and return route. Return outstanding access/referral work to its own task. An attempted call, voicemail, automated referral, Philippine L1 script, unanswered message, or ordinary referral transmission is not the requested human introduction.

Specialist referral — help schedule the visit#

Trigger, purpose, and standing. When the beneficiary wants scheduling help or the selected provider requires coordinated booking. This necessary §5.2-§5.3 work turns the authorized referral into an executable appointment; it does not require a navigator on a clean digital path and does not prove an encounter.

Decisive facts. Selected provider; verified scheduling endpoint; referral/order/authorization status; visit purpose; clinician-assigned urgency/deadline; available slots; beneficiary availability, modality/location, accessibility, interpreter, transport and caregiver constraints; cost/coverage unknowns; and duplicate appointment check. A desired date is not confirmed until the practice accepts it.

Procedure.

1. L0 presents current self-scheduling options that meet confirmed constraints and prevents duplicate requests.
2. The beneficiary/authorized representative may book or choose a slot directly.
3. Philippine L1 contacts phone-only or disconnected scheduling staff, submits the already-authorized request, and records offered/confirmed slots verbatim.
4. Puerto Rico L2 enters only for requested human help, relationship-sensitive negotiation, distress/disagreement, or accessibility failure.
5. If no timely slot exists, route options to beneficiary choice and any urgency concern to the authoring clinician; Philippine L1/Puerto Rico L2 do not redefine urgency.
6. Send accessible factual confirmation/reminders under approved contact rules.

Automation, people, and minutes. Connected self-scheduling is 0 Proxi human minutes. Philippine L1 manual scheduling/status pursuit is 0 / 8 / 20. Puerto Rico L2 exception support is 0 / 5 / 12. No clinician time is added unless availability creates a new clinical-risk question, counted in that clinical task.

Completion/failure and return. Complete with confirmed date/time/time zone, location/modality, provider, purpose, accommodations, prerequisites, source, and beneficiary confirmation; or truthful unscheduled/waitlist/declined outcome with next plan. Return appointment facts to disposition tracking and barrier work. A request, offered slot, waitlist, reminder, or authorization approval is not a confirmed appointment or completed visit.

Specialist referral — address practical barriers#

Trigger, purpose, and standing. When cost, coverage, transport, language, accessibility, geography, technology, caregiver availability, or another practical constraint threatens referral access. This necessary work makes the chosen referral usable and hands a separate community-service need to Manual 15; documenting a barrier is not resolution.

Decisive facts. Exact barrier and source; appointment/urgency; beneficiary preference; available accommodations/supports and current verification dates; payer or funding responsibility; interpreter/accessibility capability; transport/technology requirements; prior attempts; clinical consequence if delay persists; and whether another GUIDE service already owns the same need. Preserve multiple barriers separately (CC-E07).

Procedure.

1. L0 matches current approved support facts and prepares feasible options with costs, eligibility, unknowns, and tradeoffs.
2. The beneficiary/authorized representative may choose a clear option directly.
3. Philippine L1 verifies dynamic operational facts and implements already-approved logistics.
4. Puerto Rico L2 enters for requested help, ambiguous tradeoffs, distress/disagreement, or relationship-dependent coordination.
5. For a distinct community need such as transport, send the source-linked need and wanted result to Community connection — receive an identified need and Community connection — define the desired result. Confirm the exact receiving task and acceptance; neither proves usable transport or service connection. Return its actual result or barrier to this referral's appointment/access task.
6. If delay changes clinical risk or suitability, route the exact question to the authorized L3/U.S. medical clinician (L4) clinician.

Automation, people, and minutes. Clean match/direct choice is 0. Philippine L1 repair is 0 / 8 / 20. Puerto Rico L2 barrier support is 0 / 8 / 15. Triggered clinical consequence review is L3 5 / 10 / 20 or U.S. medical clinician (L4) 8 / 15 / 30, not both automatically. Count any shared conversation once; downstream service labor belongs to its own task.

Completion/failure and return. Complete the barrier task with implemented accommodation/support or an explicit declined/unavailable/unfunded outcome, beneficiary choice, clinical-risk disposition when needed, owner, and next plan. Return revised access facts to scheduling/disposition. A resource list, referral sent, transport reservation request, documented cost concern, or external-service acceptance without usable delivery is not barrier resolution or specialist-loop completion.

Specialist referral — confirm appointment disposition#

Trigger, purpose, and standing. After scheduling or when an appointment/encounter signal arrives. This necessary follow-through task establishes what actually happened: scheduled, completed, cancelled, declined, missed, disputed, waitlisted, or unknown. It does not interpret clinical content and does not convert a claim into visit documentation.

Decisive facts. Referral and appointment identifiers; provider/location/modality; scheduled date/time; practice scheduling/encounter status; beneficiary/caregiver report; claims or ADT-like utilization evidence where available; cancellation source/reason; outreach; duplicated appointments; and correctly matched encounter/document evidence. Each source and event/receipt time remains separate. A claim corroborates utilization but is not a clinical note.

Procedure.

1. L0 matches scheduling, encounter, cancellation, claim, and returned-document events to the exact referral and flags conflicts (CC-E08).
2. If authoritative practice data and the beneficiary's direct report agree, record the disposition without a Proxi human.
3. Philippine L1 verifies a missing or conflicting administrative status with the practice and captures the answer verbatim.
4. Ask the beneficiary directly only for facts the sources cannot establish; Puerto Rico L2 enters for refusal/confusion, changed preference, distress, or another relationship condition.
5. Route completed encounter to documentation retrieval; route cancelled/missed/declined to response; preserve disputed/unknown without guessing.

Automation, people, and minutes. Connected matching is 0 human minutes. Philippine L1 status verification is 0 / 3 / 8. Puerto Rico L2 relationship clarification is 0 / 5 / 12. No clinician enters unless the reason raises a safety/clinical-plan question, counted under the response task.

Completion/failure and return. Complete with one attributable disposition, source(s), event and verification dates, conflict resolution or remaining unknown, and next task. Return completed to visit-document work; return no-encounter to barrier/reschedule/clinical-plan work. Appointment confirmation, check-in, claim, cancellation message, or beneficiary recollection alone cannot prove every other milestone. Unknown remains open under the approved due policy; it is not converted to missed or completed.

Specialist referral — respond to a missed, cancelled, or declined visit#

Trigger, purpose, and standing. When the confirmed disposition is missed, cancelled, declined, provider-rejected, or otherwise no encounter. Necessary follow-through determines whether the beneficiary wants another attempt, a remediable barrier exists, or the clinical approach must change. D-009 successful closure is not available without an encounter and returned documentation; O-019 controls truthful non-success terminal options.

Decisive facts. Exact disposition/source/reason; who cancelled or declined and decision authority; referral urgency/current safe course; prior attempts; barriers; beneficiary preference; alternatives and waitlists; change in symptoms/circumstances; clinician-authored referral basis; safety cues; and open PCP notice/introduction obligations. Caregiver refusal does not automatically control a capable beneficiary (CC-E19).

Procedure.

1. L0 presents the known event, prior attempts, feasible logistical options, and unanswered question.
2. A beneficiary/authorized representative may clearly choose reschedule, alternate provider, pause, or decline directly.
3. Philippine L1 performs clean rescheduling/availability work; Puerto Rico L2 enters for requested help, refusal/confusion, distress/disagreement, or relationship-dependent barrier recovery.
4. If circumstances, urgency, referral need, or acceptable wait changed, the exact authorized U.S. behavioral clinician (L3) or U.S. medical clinician (L4)/treating clinician decides continue, change, withdraw clinically, or establish a safe interim plan.
5. Record the allowed continuing or non-success outcome; do not demand nonexistent visit documentation (CC-E25).

Automation, people, and minutes. Clear direct choice is 0. Philippine L1 is 0 / 8 / 20; Puerto Rico L2 0 / 8 / 15. A separate U.S. behavioral clinician (L3) review is 5 / 10 / 20 or U.S. medical clinician (L4) medical review 8 / 15 / 30, with 0 incremental when the current clinical encounter already decided.

Completion/failure and return. Complete this response with attributable reason/choice, corrected barrier or alternative, clinical-risk disposition when triggered, new appointment or explicit continuing plan, and unresolved obligations. Return reschedule to scheduling, alternative to choice, and plan change to Care Plan/clinical work. Outreach, voicemail, another referral request, or exhausted unapproved attempts is not successful referral closure.

Specialist referral — obtain visit documentation#

Trigger, purpose, and standing. After a specialist encounter is confirmed or an expected result becomes due. RFA §5.2 requires documentation from the visit and resulting care-plan changes or recommendations to be received. The task obtains the correctly matched source artifact; it does not clinically accept it.

Decisive facts. Referral/encounter identifiers; provider and custodian; encounter date/type; expected document class; authorized request/release basis; verified records endpoint; existing exchange/portal/HIE candidates; request and response events; patient/encounter match; page/completeness/signature status; source author; and any expected separately pending result. A claim, after-visit billing code, or generic portal note does not establish the correct document.

Procedure.

1. L0 searches permitted connected sources, matches candidate artifacts to person/referral/encounter, preserves originals, and identifies objective defects.
2. If a complete correctly matched record arrives, ingest it with provenance and route it; no human record chaser is required.
3. Philippine L1 sends/tracks only an already-authorized focused records request and resolves administrative endpoint/status defects.
4. Puerto Rico L2 enters only for a beneficiary relationship/permission clarification that cannot be resolved directly.
5. Quarantine wrong-patient, wrong-encounter, corrupt, illegible, partial, unsigned when signature is required, or internally inconsistent material under CC-E24; safety content bypasses routine pursuit.

Automation, people, and minutes. Clean retrieval/matching is 0 human minutes. Philippine L1 pursuit is 0 / 8 / 20. Puerto Rico L2 is 0 / 5 / 12 only if triggered. Outside-provider/records work is excluded. Legal Counsel enters only for a complete genuine uncovered legal question under O-021, not ordinary missing permission facts.

Completion/failure and return. Complete with original artifact, authenticated source, person/encounter/referral match, receipt date, completeness/defect result, extraction provenance, and route to clinical review. Return missing/defective status to pursuit. Receipt does not prove recommendation acceptance, Care Plan change, beneficiary explanation, child-service completion, or D-009 closure.

Specialist referral — pursue missing or incomplete documentation#

Trigger, purpose, and standing. When expected visit documentation is absent as of an approved due condition, or received material is objectively incomplete, unreadable, corrupt, wrong-patient, wrong-encounter, missing the requested recommendation, or otherwise unusable. This necessary work repairs the source artifact; it does not invent the missing clinical content.

Decisive facts. Encounter and expected document; custodian/verified endpoint; exact defect; original artifact; prior requests/responses; disclosure/request authority; clinically assigned timing; separately pending tests/results; provider statement that no record exists; and approved retry/exhaustion policy. Exact clocks remain open under O-004/O-020.

Procedure.

1. L0 identifies the precise missing item/defect, suppresses duplicate requests, and prepares a source-specific correction request.
2. Philippine L1 contacts the custodian through the permitted route, states the exact defect without interpreting recommendations, and records responses verbatim.
3. Re-match every returned artifact; do not overwrite the defective original.
4. If the provider says no record exists, the document remains unavailable and routes to an authorized non-success/safe-plan decision; Philippine L1 cannot deem it unnecessary.
5. If the defect may conceal an urgent instruction or safety issue, invoke the clinical/safety pathway while document pursuit continues.
6. Puerto Rico L2 enters only for a relationship-sensitive beneficiary fact.

Automation, people, and minutes. Routine detection/tracking is 0. One shared Philippine L1 pursuit episode is 3 / 8 / 20, not charged again for the obtain-card work. Puerto Rico L2 is 0 / 5 / 12. A clinician is not added merely to chase or administratively bless the record; any safe provisional clinical disposition is counted in its clinical task.

Completion/failure and return. Complete this pursuit with corrected/validated artifact, explicit no-record/refusal result, or approved bounded non-success disposition; record all attempts, responses, remaining risk, owner, and next plan. Return valid material to routing/review. Fax success, repeated voicemail, exhausted invented attempts, or a model reconstruction is not documentation or referral-loop completion (CC-E09).

Specialist referral — route recommendations for clinical review#

Trigger, purpose, and standing. When correctly matched visit documentation, specialist findings, recommendation, order, refusal, or separately returned result is received. Necessary delivery work places source-native content with the professional whose authority covers the question and, when applicable, the actively co-managing PCP. Routing is not review or acceptance.

Decisive facts. Authenticated provider/source; encounter; original artifact; extracted recommendation with provenance; recommendation versus effective order/status; affected diagnosis/treatment/medication/function/behavior/safety domain; current beneficiary location; relevant current Care Plan/regimen; conflicts; urgency signal; appropriate reviewer authority; PCP co-management/applicability; and expected review return. Keep pending test/result obligations separate (CC-E37).

Procedure.

1. L0 preserves the original, creates a source-faithful index, compares literal differences, and identifies objective defects/conflicts without choosing a position.
2. Route nursing/function/transition/safety content to an authorized U.S. RN (L3); behavioral/psychosocial content to U.S. behavioral clinician (L3); diagnosis, treatment, prescribing, medication, or higher-authority medical content to U.S. medical clinician (L4)/treating clinician.
3. Do not add RN plus U.S. medical clinician (L4) automatically; send each exact protected question to the narrowest authorized professional.
4. Philippine L1 repairs only source/identity/routing defects; Puerto Rico L2 resolves only genuine relationship ambiguity.
5. External PCP sharing/review uses the applicable consultation/release route, not a silent copy.

Automation, people, and minutes. Clean internal routing is 0 human minutes. Philippine L1 correction is 0 / 3 / 8; Puerto Rico L2 0 / 5 / 12 if separately triggered. The receiving clinical review is not counted here; it belongs to the actual review/clarification act. Any external V1 release remains under O-021.

Completion/failure and return. Complete with authenticated source, matched encounter/referral, original artifact, extracted content/provenance, exact reviewer/question, acceptance and due condition. Return source defects to pursuit and urgent cues to safety response. Inbox receipt, OCR, summary, generic clinician-pool queue, PCP carbon copy, or newest-note assumption is not clinical review.

Specialist referral — clarify conflicting or incomplete recommendations#

Trigger, purpose, and standing. When specialist advice is incomplete, internally inconsistent, conflicts with the current Care Plan/regimen, PCP or another specialist recommendation, or does not fit current circumstances. This necessary clinical act protects the beneficiary from acting on unresolved competing advice; recency alone does not decide.

Decisive facts. Each verbatim recommendation/order and source; provider identity/authority; encounter/effective dates; affected condition/medication/action; supporting evidence; current clinical state/location; beneficiary goals and reported implementation; existing instructions; responsibility/co-management statements; missing facts; and prior clarification attempts. Distinguish a specialist recommendation, effective outside order, and GUIDE proposal. Nonexhaustive examples include cardiology advice conflicting with a falls plan or behavioral-health advice interacting with a medication regimen.

Procedure.

1. L0 constructs a side-by-side source-linked comparison and drafts focused questions; affected instructions remain held unless an authorized current course already exists.
2. Philippine L1 obtains existing records/response logistics only.
3. The beneficiary-location-authorized U.S. behavioral clinician (L3) professional resolves only within behavioral/psychosocial scope; U.S. medical clinician (L4)/treating/prescribing clinician decides diagnosis, treatment, medication applicability, current course, urgency, and which outside clinicians must be contacted.
4. External PCP/specialist supplies or corrects that provider's own position; Proxi cannot impose agreement.
5. Record chosen course, retained dissent/uncertainty, rationale, communications, and child work; safety cues bypass routine timing.

Automation, people, and minutes. Philippine L1 factual pursuit is 0 / 8 / 20. Separate U.S. behavioral clinician (L3) judgment is 5 / 10 / 20 or U.S. medical clinician (L4) medical judgment 8 / 15 / 30; use one actual qualified act unless two distinct scopes are required. Puerto Rico L2 0 / 5 / 12 only for separate beneficiary relationship work. Outside clinicians' acts are excluded.

Completion/failure and return. Complete with authoritative within-scope disposition, rationale, current instruction/safe course, retained conflict, required notifications, and Care Plan/medication effect. Return missing facts to pursuit and accepted result to incorporation/explanation. A summary, provider silence, unexplained concurrence, newest date, or navigator interpretation cannot resolve CC-E12.

Specialist referral — incorporate the reviewed outcome#

Trigger, purpose, and standing. After the authorized clinical reviewer records accepted, rejected, conflicting, uncertain, or reviewed-no-change findings. RFA §5.2 loop closure includes resulting Care Plan changes; this task records the reviewed effect without treating the specialist's recommendation or document receipt as automatically accepted.

Decisive facts. Attributable clinical review/disposition; accepted and rejected elements; rationale and current instruction; beneficiary goals/choices; affected Care Plan content/version; responsibilities; pending tests/results; medication implications; follow-up; effective timing; unresolved conflicts; and existing open child tasks. Separate coordination facts from protected clinical content and preserve source links.

Procedure.

1. L0 drafts only the exact Care Plan delta and proposed responsibility/follow-up links supported by the reviewed result.
2. Reuse the reviewing clinician's protected content; return missing clinical wording to that clinician rather than adding a second reviewer.
3. Obtain a direct beneficiary/representative choice where the plan requires one; Puerto Rico L2 enters only for requested help, ambiguity, disagreement, distress, accessibility failure, or a separately required planning interaction.
4. The authorized clinician confirms only new or corrected protected content not already finalized in the same review.
5. Record approved revision or attributable reviewed-no-change; route distribution and child execution separately.

Automation, people, and minutes. Clean drafting/linking is 0 human minutes. Puerto Rico L2 plan-choice support is 0 / 5 / 12. Additional clinician contribution is 0 / 3 / 7, normally 0 incremental because it is included in the preceding review. Count Care Plan human work once in its owning episode, not again here.

Completion/failure and return. Complete with source review, exact approved delta or reviewed-no-change result, current plan/version status, beneficiary choice, responsibilities, pending dependencies, and downstream links. Return the plan result to explanation and distribution. A specialist note, recommendation extraction, task opening, draft edit, owner assignment, or beneficiary notification is not plan reconciliation. Unresolved conflict keeps the affected element held while independent plan content may continue.

Specialist referral — explain the outcome and next work#

Trigger, purpose, and standing. After an authorized reviewed result and current plan/instruction exist, and again when a correction materially changes what the person must understand. This necessary §5.2-§5.3 work tells the beneficiary what was learned, what changed or did not, what remains uncertain, and who will do the next work; it does not prove that child work occurred.

Decisive facts. Clinician-reviewed result and approved plain-language rendering; current instruction; accepted/rejected/uncertain recommendations; Care Plan effect; next tests/referrals/treatment/medication/monitoring; owners and timing; warning/problem-contact instructions authored by clinicians; recipient/participation authority; language/accessibility; and questions. A digital approved explanation may be used on a clear accessible path; delivery is not comprehension.

Procedure.

1. L0 renders the exact approved result, assignments, dependencies, and contact route without adding clinical meaning.
2. Deliver through the approved accessible modality and capture corrections/questions.
3. A clear authenticated acknowledgement may complete the clean explanation path with no default navigator or clinician.
4. Puerto Rico L2 enters for requested human help, accessibility recovery, distress/disagreement, relationship support, or an approved bounded understanding check; Puerto Rico L2 explains logistics and faithfully reinforces approved content.
5. New individualized clinical questions return to the authoring/authorized clinician.
6. Record understanding or limitation, not merely yes/no assent.

Automation, people, and minutes. Clean approved delivery is 0 human minutes. Puerto Rico L2 support is 0 / 5 / 12. Separate clinician explanation is 3 / 7 / 15, or 0 incremental when performed in the same review encounter. Do not add both unless they perform distinct acts.

Completion/failure and return. Complete with recipient/authority, exact content/version, performer if human, modality/accommodations, questions/answers or routing, understanding/limitation, and next actions. Return each promised child item to its owner. Message sent, voicemail, portal availability, navigator paraphrase of unreviewed content, or silence is not useful explanation; explanation itself does not establish order, scheduling, treatment, possession, use, or monitoring completion.

Specialist referral — carry forward new work#

Trigger, purpose, and standing. When the reviewed specialist outcome creates a distinct referral, test, treatment-coordination, medication, monitoring, equipment, community-service, caregiver, or ongoing-follow-up obligation. This necessary execution step returns exact work to the proper service without making referral closure depend on future child-service results that are not part of the referral product.

Decisive facts. Reviewed result/source; Care Plan effect; each clinical or operational child action; authorized owner; prerequisite/order; expected result; assigned timing; beneficiary choice; outside acceptance; pending-result reviewer/route; duplicates; and destination. An external recommendation cannot assign a Proxi or outside performer.

Procedure.

1. L0 converts only reviewed accepted work into discrete source-linked child obligations and de-duplicates existing work.
2. Route administrative scheduling/retrieval/status to software/Philippine L1; route relationship-dependent work to Puerto Rico L2 only under D-021; route each protected order/decision directly to the authorized L3/U.S. medical clinician (L4)/treating clinician.
3. Obtain acceptance and first required step from the actual receiving owner where applicable; outside-party nonacceptance remains explicit.
4. Preserve pending-result reviewer/return route under CC-E37.
5. Return actual later results to their owning services; do not rewrite the completed referral clinical product or count shared labor twice (D-016).

Automation, people, and minutes. Clean creation/routing is 0 human minutes. Philippine L1 objective exception work is 0 / 4 / 10; Puerto Rico L2 human coordination 0 / 5 / 12. New clinical work uses the child task's own L3/U.S. medical clinician (L4) band and is 0 here. Outside clinician/service acts are excluded.

Completion/failure and return. Complete this task with exact child obligation, source, destination, accepted owner/first step or explicit refusal/unresolved dependency, timing, and cross-pillar return. A task list, generic owner, referral/order sent, scheduled test, result posted, or accepted handoff is not the future service result. Successful specialist-loop closure still requires the D-009 manifest, but future child monitoring or treatment may remain independently open without erasing the completed encounter/review/plan-reconciliation product.

Transition — detailed task cards#

Transition — detect the move between home and a care setting#

When, purpose, and status. Open when an ADT notification, claim/encounter signal, facility message, beneficiary/caregiver report, or care-team report suggests entry, discharge, or transfer. Detection is necessary delivery work supporting the §5.4 transition service; the specific feed, matching logic, and alerts are Proxi design. An ADT event proves only the event content it carries, not diagnosis, current location, discharge readiness, risk, RCC status, hospice enrollment, or long-term residence (SRC-CMS-ADT-COP).

Decisive facts. Preserve source, event and receipt times, patient identifiers, stated facility/unit, event type, reporter, confidence/match defects, possible duplicate/correction/retraction, and any current-location evidence. Facility name, claim type, or historical address alone never classifies the setting or status.

Procedure.

1. Software matches without overwriting prior events and links probable duplicates.
2. A high-confidence supported event opens establishment work; uncertain identity or event type opens a factual verification task while safe support proceeds.
3. A person report is recorded verbatim and can trigger immediate contact even before records arrive.
4. A correction/retraction preserves both histories and invokes CC-E15; a rapid new event opens linked work under CC-E40. Detection cojoins the transition envelope but completes no medication, clinical, status, or service child task.

People and minutes. Clean connected detection: 0. Philippine L1 Philippine administrative matching/endpoint verification: 2 / 5 / 10. Puerto Rico L2: 0 / 5 / 12 only for requested human recovery, ambiguity, distress, disagreement, accessibility, or relationship work. No clinician enters merely because an ADT arrived.

Completion/failure/return. Complete with a source-attributed candidate or confirmed event, match disposition, linked episode, and next factual task. Unmatched, conflicting, or retracted data remains explicit; support is not delayed. Tests: duplicate ADT; wrong patient; late discharge; report without feed; facility-name RCC inference; same-day ED return.

Transition — establish the current situation#

When, purpose, and status. Begin after any credible transition signal, including one with missing records. The purpose is to establish the minimum current factual picture needed for support. This is necessary §5.4 delivery work; Proxi's fact manifest and classification hold are design choices under O-024.

Decisive facts. Seek from/to setting, exact unit or level when known, direction, event and awareness dates, current physical location and source/time, expected duration, next planned move, treating contacts, and whether the person is currently at home, in transit, or in another setting. Keep administrative admission/discharge status separate from clinical condition and eligibility/status facts. Do not infer RCC approval/compliant-arrangement predicates, memory-care residence, hospice-benefit enrollment, or long-term-nursing status from facility name, claim, room, or one report (CC-E31, CC-E32).

Procedure.

1. Software assembles source-separated facts and contradictions.
2. Philippine L1 verifies objective facility, unit, date, and endpoint facts only when disconnected.
3. Present remaining gaps for direct authenticated beneficiary/caregiver confirmation.
4. If location is unknown, L0–Puerto Rico L2 may collect and connect, but licensed acts wait for location authority except emergency-safe connection (CC-E43).
5. If status predicates matter, open the separate status workflow; do not stop transition support.
6. Preserve a planned second transition as linked future work, not as closure of the current episode.

People and minutes. Clean data plus direct confirmation: 0. Philippine L1: 3 / 7 / 15. Puerto Rico L2: 0 / 6 / 15 only under D-021. No clinical review is required for classification; L3/U.S. medical clinician (L4) enters only for a separate clinical question.

Completion/failure/return. Complete with dated current-setting facts, source/conflict disposition, current location, and next transition status. Unknowns remain open without becoming false. Tests: ED observation; swing bed; short SNF; move during call; conflicting dates; unknown permanence; hospice-looking facility without enrollment evidence.

Transition — contact the beneficiary or caregiver#

When, purpose, and status. Contact starts promptly after a credible transition signal to learn what happened, what the person understands, current lived needs, and desired help. §5.4 supports transition coordination; Proxi's prepared direct digital/voice route and proposed 48–72-hour home-recovery target are design, not a CMS deadline (O-004, SRC-AHRQ-RED-2025). Missing records do not postpone contact or safe support.

Decisive facts. Use verified identity, current location when safely obtainable, preferred modality/language/accessibility, caregiver participation versus decision authority, safe-contact restrictions, known event facts, record gaps, and prior attempts. Ask for the person's report verbatim; do not make a clinical finding from fluency, distress, silence, or an ADT event.

Procedure.

1. Software presents known facts and asks the beneficiary or permitted caregiver to confirm/correct, describe current circumstances, state needs, and choose help.
2. A clear authenticated response can proceed without paid navigator validation.
3. Puerto Rico L2 enters for an actual requested human conversation, caregiver support, distress, conflict, accessibility failure, substantive navigator contact, or relationship-dependent barrier.
4. Symptoms, safety concerns, medication problems, or urgent-advice requests immediately enter the approved clinical/emergency route; Philippine L1/Puerto Rico L2 do not decide that the issue can wait.
5. No response invokes only approved attempts; silence is not stability or refusal.

People and minutes. Accessible direct completion: 0. Philippine L1 contact repair/first answer: 2 / 5 / 10. Puerto Rico L2 recovery conversation: 6 / 15 / 30. Count one shared conversation once across transition, Ongoing, and other actual content. Clinical time belongs to the receiving clinical task.

Completion/failure/return. Complete with attributable report, corrections, requested help, communication result, and routed concerns—not merely an attempted call. Tests: direct digital response; no answer; caregiver without authority; distress; aphasia/interpreter need; symptom at 2 a.m.; report contradicting facility data.

Transition — obtain transition records and instructions#

When, purpose, and status. Start as soon as the transition is known and continue in parallel with support. The purpose is to obtain source instructions and records needed for §5.4 coordination. Proxi's document manifest, defect checks, and pursuit workflow are design; absent records never mean no change (CC-E14, CC-E42).

Decisive facts. Request the matched discharge/transfer summary, after-visit instructions, medication lists and orders, diagnoses as documented by the treating source, pending tests/results, follow-up orders, clinician-supplied warning signs, equipment, home-health/service orders, material diet/activity instructions, and responsible contacts. Retain author, source, encounter, version, event/receipt dates, signatures where relevant, and defects. A claim, ADT notice, portal listing, or OCR summary does not substitute for the source document.

Procedure.

1. Software retrieves authorized accessible artifacts, matches them to person/encounter, preserves originals, indexes facts, and flags missing pages/conflicts.
2. Philippine L1 pursues already-authorized administrative records and exact defects.
3. A partial, illegible, wrong-patient, wrong-encounter, unsigned, or internally inconsistent artifact is quarantined from satisfaction under CC-E24; usable portions remain attributed.
4. If no usable plan exists, continue safe provisional support through the authorized clinical route rather than waiting.
5. Any new instruction is a candidate until source/authority is verified; Philippine L1/Puerto Rico L2 do not relay it as operative.

People and minutes. Connected retrieval: 0. Philippine L1 pursuit: 4 / 10 / 25. Puerto Rico L2: 0 / 5 / 12 only for a permission/relationship/accessibility exception. L3/U.S. medical clinician (L4) reviews only clinically material content in its owning task.

Completion/failure/return. Complete with the applicable artifact manifest, source/encounter match, defects, and routed obligations. Missing material stays open with attempts, safeguard, owner, and next action. Tests: weekend discharge; wrong encounter; partial AVS; no prescription; late correction; mixed valid/invalid pages; records still absent after support begins.

Transition — identify immediate needs and barriers#

When, purpose, and status. Screen after initial contact and whenever new transition information arrives. The purpose is to identify practical or reported clinical needs created by the move so help starts early. §5.4 requires transitional care management; the structured screen and domain list are Proxi/AHRQ-informed design, not a new CMS checklist.

Decisive facts. Collect source-attributed reports about symptoms, safety, medication access/use, equipment, oxygen/supplies, home health, food, housing, transport, personal care, caregiver availability/capacity, accessibility, follow-up access, and another planned move. Preserve baseline, what changed, timing, current location, existing orders/supports, beneficiary choice, and unknowns. A missed claim, absent delivery event, or caregiver concern is a signal, not a diagnosis or risk determination.

Procedure.

1. Software asks bounded accessible questions, merges known facts, and suppresses repeats.
2. A direct clear answer can populate the need list without Puerto Rico L2 blessing.
3. Objective disconnected logistics go to Philippine L1; beneficiary preference, distress, conflict, caregiver support, or accessibility recovery goes to Puerto Rico L2.
4. Symptoms, safety, behavior, safeguarding, or clinical uncertainty route directly to the exact U.S. RN (L3)/behavioral or U.S. medical clinician (L4)/treating clinician; immediate danger uses the emergency route.
5. Community needs open the exact Referral task; equipment/home-health logistics remain administrative unless an alternative or consequence requires clinical judgment.
6. Keep child acceptance separate from service completion.

People and minutes. Clean direct screen: 0. Philippine L1 factual repair: 3 / 8 / 18. Puerto Rico L2 triggered needs conversation: 6 / 15 / 30. L3/U.S. medical clinician (L4) minutes are recorded only in the receiving clinical act, not again here.

Completion/failure/return. Complete with each need/no-need/unknown result, provenance, chosen help, receiving task, and immediate safeguard. Silence or an incomplete screen is not no need. Tests: equipment backorder; no home-health start; caregiver collapse; food issue; no response; acute dyspnea; conflicting caregiver/beneficiary reports; multiple barriers.

Transition — obtain clinical or emergency response#

When, purpose, and status. Invoke when a report or validated source raises symptoms, deterioration, safety, behavioral crisis, safeguarding concern, medication problem, conflicting instructions, or a request for clinical advice. The purpose is to obtain the correct professional response without nonclinical triage. The immediate interrupt is Proxi safety design; exact urgency classes, hours, response targets, backup, and failed-connection policy remain O-004/O-054.

Decisive facts. Capture identity, callback, current physical location when safely obtainable, reporter, exact words, onset/time, known current instructions, actions already taken, connection attempts, and source artifacts. Do not require a perfect packet before emergency-safe connection. A Philippine nursing credential does not authorize U.S. triage, assessment, medication instruction, or a wait-until-morning decision (D-026, X-019).

Procedure.

1. Philippine L1 or Puerto Rico L2 records verbatim and stops ordinary advice.
2. An explicitly approved immediate-connect condition or caller-reported emergency uses the configured emergency-safe route now. A non-emergency clinical branch is SOP DESIGN BLOCKED — NOT OPERATIONAL wherever O-054 has not named its hours, scope, backup, and failed-connection route.
3. Confirm receiver identity, authority, and acceptance; an attempt is not a handoff.
4. An approved L3 route performs only within scope; U.S. medical clinician (L4)/treating clinicians make medical decisions.
5. Record connection and disposition separately, then return exact successors. Parent transition work remains open.

People and minutes. Shared nonclinical intake/connection Philippine L1 or already-engaged Puerto Rico L2: 3 / 7 / 15. L3 focused response: 5 / 15 / 30+; U.S. medical clinician (L4): 8 / 20 / 40+. Count the same 24/7/Medication/transition event once. No mandatory overnight Puerto Rico L2 or in-house clinician shift is inferred.

Completion/failure/return. Handoff completes only on accepted transfer; response completes on attributable disposition. Failed connection stays active with an approved safeguard, never an invented morning delay. Tests: 2 a.m. status call; chest pain; unknown location; disconnected clinician; caregiver panic; medication question; emergency transfer with unresolved equipment task.

Transition — start medication reconciliation#

When, purpose, and status. Open linked Medication work for every applicable transition under RFA §5.4 using the pre-transition regimen, facility administration, discharge orders, pharmacy events, household supply, and reported current use. This card initiates and supplies evidence; it is not the reconciliation product. The public RFA does not name the transition actor, and O-028/O-PA-001 must approve the actual taxonomy.

Decisive facts. Preserve each source/author/date, medication identity, intended versus administered/dispensed/possessed/reported-used states, allergies, discrepancies, missing records, location, relevant clinicians, and safety reports. A discharge list, fill event, or case opening does not establish the intended regimen. The completed Medication M14/M15 professional product remains separate from order, dispense, possession, instruction, implementation, and monitoring milestones.

Procedure.

1. Software opens and tracks the linked case, reusing transition evidence without forcing duplicate reconciliation because Care Coordination opened.
2. Philippine L1 pursues objective source artifacts; Puerto Rico L2 contributes only requested relationship/use context under D-021.
3. The actual Medication professional returns the route's attributable required result. Prescribing authority is mandatory when this is a §7.1 review occasion or an intended-regimen, prescribing or deprescribing decision; a regular RN or navigator does not substitute. Public §5.4 alone does not name the transition actor. A separate §5.4-only actor/product must be approved under O-028/O-PA-001 rather than inferred as RN or universally prescribing-clinician work. The unresolved dependent branch is design-blocked; source preparation and approved safety work continue.
4. A safety concern bypasses routine collection to the approved response route.
5. Return the professional outcome and each downstream obligation separately; future monitoring never erases an already completed attributable product.

People and minutes. Connected initiation: 0. Philippine L1 evidence exception: 3 / 8 / 18. Puerto Rico L2 context: 0 / 5 / 12 when triggered. The attributable professional act and minutes are owned once by M14/M15, not charged again here.

Completion/failure/return. Record intake, sources, discrepancies and the accepted receiver; keep the applicable duty open until its actual authorized Medication result returns. Use M14/M15 for the required prescribing-authority reconciliation product; do not invent an alternative transition-only result before O-028/O-PA-001 approves it. Opening/acceptance never fulfills §5.4. An incomplete product with safeguards remains incomplete; future execution/monitoring stays separate. Tests: no discharge list; conflicting lists; current M14 product reused; no reported change but duty still applicable; §5.4-only taxonomy unresolved; wrong patient; case opened/no result; late order correction.

Transition — identify required follow-up visits#

When, purpose, and status. Identify follow-up after transition records or direct reports reveal a visit, test, laboratory/imaging/pathology result, home-health encounter, hospice contact, or other clinical return. This supports §5.4/§5.5 coordination. Proxi's executable manifest and pending-result controls are AHRQ-informed design.

Decisive facts. Preserve the source instruction, purpose, responsible clinician/organization, due or expected timing, scheduled versus unscheduled state, location/modality, required records, coverage/order prerequisites, current physical location where licensure matters, and who will review and communicate each result. A facility name, claim, order, or appointment suggestion does not establish responsibility, acceptance, or clinical review.

Procedure.

1. Software extracts literal instructions, compares existing appointments, and separates visits from tests and pending results.
2. Clear source instructions become scheduling or tracking work without navigator review.
3. Philippine L1 verifies administrative requirements or disconnected status.
4. Conflicting, clinically ambiguous, missing-purpose, or unsafe timing goes directly to the appropriate L3/U.S. medical clinician (L4)/treating clinician.
5. For every pending test/result, record expected timing, named authorized reviewer, return route, safeguards, and earlier-action condition; posted is not reviewed (CC-E37).
6. Equipment/home-health follow-up stays logistical unless a proposed alternative or consequence requires judgment.

People and minutes. Clean extraction: 0. Philippine L1 verification: 3 / 7 / 15. Puerto Rico L2: 0 / 5 / 12 for requested help, accessibility, distress, conflict, or relationship work. L3 5 / 10 / 20 or U.S. medical clinician (L4) 8 / 15 / 30 only for the exact clinical ambiguity, not every follow-up.

Completion/failure/return. Complete with an actionable manifest: purpose, owner, timing, prerequisites, status, result reviewer, communication route, and next task. Unclear or unaccepted ownership stays open with safeguard. Tests: pending pathology without reviewer; appointment already booked; contradictory discharge dates; lab posted but unreviewed; wrong clinician; no order; patient moved; equipment check mislabeled as clinical visit.

Transition — arrange follow-up appointments#

When, purpose, and status. Arrange only after the follow-up purpose, intended provider/test, source instruction or authorized clinical decision, and beneficiary constraints are known. Scheduling is necessary delivery work supporting §5.4; connected scheduling, reminders, and barrier workflows are Proxi design. An appointment is not an encounter, result, or accepted clinical responsibility.

Decisive facts. Use the authorized follow-up manifest; verified destination; order/referral/coverage prerequisites; clinically assigned timing when applicable; beneficiary availability and choice; location/modality; language/accessibility; transport/caregiver/technology needs; safe-contact restrictions; and prior attempts. Do not infer date, location, or service from a facility name or claim alone.

Procedure.

1. Software offers connected slots within approved constraints and records a direct authenticated choice.
2. Philippine L1 handles phone-only scheduling, dynamic availability, missing administrative prerequisites, and objective status pursuit.
3. Puerto Rico L2 enters only for actual requested human help, negotiation, distress, conflict, accessibility failure, caregiver support, or a navigator-due contact; clear scheduling does not default to Puerto Rico L2.
4. If no feasible slot meets clinician-assigned timing, return the conflict to the exact clinician; Philippine L1/Puerto Rico L2 do not alter urgency.
5. Confirm the appointment with practical details and open barrier work.
6. A declined, missed, cancelled, waitlisted, or unavailable outcome remains distinct and returns to the responsible route.

People and minutes. Clean connected schedule: 0. Philippine L1: 4 / 10 / 25. Puerto Rico L2: 0 / 6 / 15 only on its entry conditions. Clinical reassessment: L3 5 / 10 / 20 or U.S. medical clinician (L4) 8 / 15 / 30, only when timing/plan changes require judgment. External scheduling labor is not Proxi-paid time.

Completion/failure/return. Complete with source instruction, chosen appointment, destination, date/time/timezone, modality/location, prerequisites, accommodations, confirmation source, and beneficiary notification. “Request sent” is pending. Tests: connected self-schedule; phone-only office; waitlist; no interpreter; coverage denial; caregiver selects without authority; clinical deadline missed; appointment later cancelled.

Transition — coordinate with involved healthcare providers#

When, purpose, and status. Coordinate when a transition creates a specific information, responsibility, review, or action obligation for the PCP, specialist, discharging facility, home health, hospice, pharmacy, laboratory, or other healthcare endpoint. Section 5.4 requires transition coordination; Proxi's focused packet, source tracking, and return manifest are design. Do not create routine outreach without a named result.

Decisive facts. Identify exact recipient and current relationship, requested result, relevant source facts, beneficiary preferences, minimum necessary content, current approved care-plan/medication references, contradictions, recipient endpoint, disclosure basis/restrictions, clinically assigned timing, return route, and reviewer. Facility name, prior claim, or old endpoint does not prove current relationship or authority.

Procedure.

1. Software assembles one recipient-specific source-linked packet and de-duplicates requests.
2. Philippine L1 verifies objective recipient/endpoint facts and pursues administrative response.
3. Puerto Rico L2 performs substantive relationship-dependent coordination only under D-021.
4. L3/U.S. medical clinician (L4)/outside provider (L5) authors the protected question, instruction, or disposition within scope; no generic clinician review is added.
5. The V1 release act remains SOP DESIGN BLOCKED — NOT OPERATIONAL until O-021 names the canonical performer, content, and evidence; independent preparation and urgent safe connection continue.
6. Track release, delivery, receipt, response, clinical review, and implementation separately.

People and minutes. Software clean preparation/tracking: 0. Philippine L1: 4 / 10 / 25. Puerto Rico L2: 0 / 6 / 15. Clinical authorship/review L3 5 / 10 / 20 or U.S. medical clinician (L4) 8 / 15 / 30, only if required. V1 release placeholder 1 / 2 / 4 cannot run before O-021.

Completion/failure/return. Complete the child obligation only with its requested result or truthful authorized non-success, source, reviewer, and next action; acceptance is not execution. Tests: wrong endpoint; PCP and facility conflict; hospice-looking facility without enrollment; packet prepared but blocked; response received unreviewed; urgent question during release hold; duplicate provider request.

Transition — hand community-service needs to the appropriate service#

When, purpose, and status. Open when the transition identifies meals, transport, personal care, housing/environmental support, or another nonclinical community need and the beneficiary wants assistance. The transition recognition supports §5.4; the receiving Referral and Services procedure under §6 owns resource matching and connection. A handoff is not service delivery.

Decisive facts. Preserve the exact need and desired result, source/time, current setting and service area, beneficiary constraints and choice, urgency as assigned by the correct route, relevant care-plan context, existing resources/attempts, permission/disclosure facts, and any clinical safeguard. Do not infer eligibility, availability, or need resolution from a claim, directory listing, accepted referral, or facility label.

Procedure.

1. Software creates the minimum source-linked internal referral and checks for an existing matching need.
2. The beneficiary or authorized representative can directly accept, decline, defer, or correct the offered help.
3. Puerto Rico L2 enters only for requested warm introduction, relationship support, distress, disagreement, accessibility failure, caregiver support, or navigator-due work.
4. The receiving service accepts the child obligation and applies its own inventory, choice, release, connection, and closure rules.
5. Keep need recognition, handoff acceptance, external intake, service start, and usefulness separate (CC-E26).
6. Any clinical consequence returns to the exact clinician; it does not make logistics automatic clinical review.

People and minutes. Clean internal handoff/direct choice: 0. Philippine L1 disconnected factual cleanup: 2 / 5 / 10. Puerto Rico L2 triggered handoff/warm introduction: 4 / 10 / 20. Receiving-service minutes belong there; beneficiary/outside-party acts are not Proxi-paid.

Completion/failure/return. This card completes with exact need, choice, receiving task, accepted owner, and first required step. Transition closure still requires the child outcome or named continuing-owner acceptance under approved policy. Tests: decline; duplicate referral; no current resource; accepted but no intake; transport need with urgent appointment; wrong service area; caregiver request opposed by capable beneficiary.

Transition — reinforce the transition instructions#

When, purpose, and status. Reinforce after an attributable clinician/discharging source supplies current instructions and whenever the person requests help using them. Section 5.4 supports transition assistance; plain-language rendering, accessibility support, and non-shaming teach-back are Proxi/AHRQ design (SRC-AHRQ-IDEAL, SRC-AHRQ-TEACH-BACK-3E). Reinforcement never creates, changes, or clinically interprets an instruction.

Decisive facts. Use exact current instruction/version/source, recipient and authority, warning signs supplied by the clinician, current medication instructions, appointments, pending results, equipment/services, problem-contact routes, language/accessibility needs, helper permissions, and known contradictions. A sent document, yes/no answer, or caregiver possession of the phone does not prove understanding.

Procedure.

1. Software faithfully renders approved content in the permitted modality and asks the beneficiary/permitted caregiver to explain the plan in their own words.
2. A successful direct plan-back can complete without default Puerto Rico L2.
3. Puerto Rico L2 re-explains only approved nonclinical meaning and supplies accessibility/relationship support under D-021; Puerto Rico L2 does not paraphrase new clinical meaning.
4. A clinical “why,” contradiction, individualized instruction, failed plan-back with clinical implications, or capacity concern routes to the authoring L3/U.S. medical clinician (L4)/outside provider (L5) professional.
5. Stale or conflicting instructions are withheld from self-execution until authorized disposition.
6. Record each unresolved item separately.

People and minutes. Accessible digital/direct plan-back: 0. Puerto Rico L2: 5 / 12 / 25 when human reinforcement is actually needed. Philippine L1 technical/contact repair: 2 / 5 / 10. Authoring clinician explanation: 0 additional when same encounter; otherwise L3 3 / 7 / 15 or U.S. medical clinician (L4) 5 / 10 / 20.

Completion/failure/return. Complete with exact content/version, modality, participant, plan-back result, corrections, and usable help route. Failed understanding remains open with support/safeguard (CC-E39). Tests: old AVS; interpreter need; hearing loss; contradictory lists; failed teach-back; caregiver without permission; clinical question; faithful digital success.

Transition — review returned clinical recommendations#

When, purpose, and status. Review when matched transition records or provider responses contain a recommendation, order, diagnosis, symptom finding, functional/behavioral change, safety issue, medication issue, or contradiction that could affect care. This is necessary clinical work supporting §§5.4–5.5; Proxi's prepared review packet is design. Receipt, recency, or an AI summary is not clinical acceptance.

Decisive facts. Provide authenticated source/author/encounter/version, original artifact, exact recommendation or question, current beneficiary location, current plan and medication products, beneficiary goals/choices, prior clinician positions, pending results, conflicts, missing facts, and actions already taken. Defective content remains quarantined under CC-E24. Do not choose between PCP and specialist by recency alone (CC-E12).

Procedure.

1. Software compares literal source differences and prepares the narrow question with originals.
2. Route nursing, function, transition, safety, or within-scope psychosocial questions to the beneficiary-location-authorized U.S. RN (L3)/behavioral clinician.
3. Route diagnosis, treatment, medication, prescribing, or higher-authority medical decisions to U.S. medical clinician (L4) or the applicable treating clinician.
4. The reviewer records accepted, rejected, conflicting, uncertain, or no-change disposition, rationale, safeguards, timing, and successors.
5. Pending future tests receive a reviewer, expected timing, return route, and safeguards; they do not erase a completed professional result.
6. Separate provider recommendation from any lawful order, beneficiary choice, implementation, and monitoring.

People and minutes. No nonclinical approval charge. L3: 5 / 12 / 25; U.S. medical clinician (L4): 8 / 18 / 35. Puerto Rico L2: 0 / 5 / 12 only for separate beneficiary relationship/choice support. Choose the narrowest qualified performer; do not stack Puerto Rico L2, RN, and prescriber by default.

Completion/failure/return. Complete with attributable reviewer, location authority, reviewed sources, disposition/rationale, current safe instruction or explicit limitation, and next tasks. Tests: administrative-only reply; conflicting clinicians; posted pending result; wrong encounter; incomplete note; reviewed no-change; recommendation without order; late material correction.

Transition — update the care plan#

When, purpose, and status. Return transition facts and reviewed decisions to the Care Plan when the current setting, providers, supports, responsibilities, goals, preferences, or accepted clinical recommendations changed—or when an authorized review supports no change. §§5.4–5.5 connect transition outcomes to ongoing care; the exact Care Plan completion/release mechanism remains governed by the Care Plan SOP and O-003/O-014/O-041.

Decisive facts. Use only source-linked current-setting facts, beneficiary-led choices, accepted clinical dispositions, actual provider/service responsibilities, medication product references, unresolved obligations, effective dates, superseded content, and recipient/distribution implications. A draft, imported note, handoff acceptance, or transition closure narrative does not itself amend the active plan.

Procedure.

1. Software drafts a delta against the current approved plan and marks unresolved/conflicting items.
2. Clear beneficiary choices may be captured directly; Puerto Rico L2 enters only for D-021 human-help conditions or independently required navigator work.
3. The exact L3/U.S. medical clinician (L4)/outside provider (L5) professional supplies and remains attributable for clinical content; no blanket RN or navigator approval is added.
4. Apply the Care Plan's review, beneficiary participation, approval/completion, EHR incorporation, and recipient-release rules.
5. Keep the transition child's completed result separate from Care Plan acceptance and distribution.
6. A later correction creates a successor revision; never silently rewrite history.

People and minutes. Clean factual draft/return: 0. Puerto Rico L2 choice/support: 0 / 5 / 15. L3 contribution 5 / 10 / 20 or U.S. medical clinician (L4) 8 / 15 / 30 only when new protected content is required; reuse the already-counted transition review when it produced the same contribution. Care Plan completion labor belongs to that SOP.

Completion/failure/return. This card completes with exact receiving Care Plan tasks, accepted inputs, source/performer links, and first required step; it does not prove plan activation/distribution. Tests: factual location-only change; clinical no-change; unresolved conflict; beneficiary declines revision; old plan distributed; late correction; duplicate clinician contribution.

Transition — perform post-transition follow-up#

When, purpose, and status. Follow up after the transition at clinically assigned timing; for discharge home, Proxi proposes a 48–72-hour recovery contact unless earlier timing is assigned. That timing is AHRQ-informed design, not a CMS deadline, and remains O-004/O-024. A zero-human Proxi digital factual check is also design and is not the AHRQ RED clinical-staff telephone call. The purpose is to learn whether the plan is usable without converting silence into success.

Decisive facts. Prepare the current transition plan, medication/product status, appointments, pending results, equipment/home-health/services, caregiver availability, living arrangement, prior barriers, warning signs supplied by clinicians, open obligations, preferred contact route, and direct source events. Future result availability is not reviewer disposition; a delivery event is not usability.

Procedure.

1. Software presents the person-specific open items and accepts authenticated direct status/choice.
2. Clear digital/direct confirmation can complete factual follow-up without default Puerto Rico L2.
3. Philippine L1 verifies disconnected appointment, equipment, home-health, pharmacy, or record status.
4. Puerto Rico L2 enters for requested human recovery, caregiver support, distress, conflict, accessibility, substantive navigator contact, or relationship barrier.
5. Symptoms, safety, medication concerns, or clinical uncertainty bypass routine follow-up to the approved professional/emergency route.
6. A new transition opens linked work without erasing this episode (CC-E40).

People and minutes. Clean direct follow-up: 0. Philippine L1 factual verification: 3 / 8 / 18. Puerto Rico L2 recovery contact: 6 / 15 / 30. L3/U.S. medical clinician (L4) time belongs to the resulting clinical task. One conversation cojoins actual Ongoing/Medication/Care Plan content once under D-016.

Completion/failure/return. Complete with attributable status for each due item, new needs, communication outcome, exact successors, and next timing. No answer, message sent, or blanket “doing well” is insufficient. Tests: no response; medication obtained but not understood; equipment delivered unusable; home health missed; pending result posted; new ED visit; caregiver unavailable; direct clean response.

Transition — continue unresolved work#

When, purpose, and status. Continue after a transition obligation remains pending, failed, declined, disputed, or accepted by a named continuing party. This is necessary §§5.4–5.5 follow-through; retry counts, escalation clocks, non-success outcomes, and parent manifests remain open under O-004/O-019/O-024. Tracking must not manufacture contact or service credit.

Decisive facts. Preserve each child obligation, source, applicability, expected result, owner acceptance, due condition, attempts, response, safeguard, beneficiary choice, dependencies, and parent relationship. Medication review, order, dispense, possession, pending-result review, appointment, equipment, home service, community connection, instruction comprehension, and Care Plan update remain distinct.

Procedure.

1. Software tracks matched events, suppresses duplicate reminders, and surfaces only a configured due/failure condition.
2. Philippine L1 pursues disconnected administrative status within approved limits.
3. Puerto Rico L2 enters only for requested/required human recovery, distress, disagreement, accessibility, caregiver support, or relationship work.
4. Clinical nonresponse or changed risk returns directly to the exact L3/U.S. medical clinician (L4)/outside provider (L5) professional; Philippine L1/Puerto Rico L2 do not define safe exhaustion.
5. Record each child as completed, pending, declined, unavailable, accepted by a continuing owner, or truthfully unresolved; acceptance is not service completion.
6. Apply only the route-specific, applicability-aware parent manifest (O-019/O-024); a future result or monitoring item does not undo an already completed professional product.

People and minutes. Clean tracking: 0. Philippine L1 pursuit: 3 / 8 / 20 per exception episode. Puerto Rico L2 recovery: 0 / 6 / 15. Clinical time is recorded in the owning act. Never sum each card's potential band into one episode.

Completion/failure/return. Complete this tracking cycle with each due item's truthful state, safeguard, owner, and next-return status; do not impose a universal all-children-finished gate. A reminder or assigned owner is not resolution. Tests: missing prerequisite before clinical review; future pending result after completed review; accepted home-health handoff/no start; beneficiary decline; late result; repeated nonresponse; rapid readmission; false parent closure.

Additional coordination — detailed task cards#

Additional coordination — describe the need and desired result#

When, purpose, and status. Open when dementia or a co-occurring condition creates a coordination need not already owned by outside-PCP, specialist, transition, Medication, Referral, or another exact task. The purpose is to state the person's problem and wanted result without inventing a clinical question. Section 5.5 is the public coordination anchor; Proxi's intake envelope and de-duplication are design.

Decisive facts. Preserve reporter identity and authority, beneficiary's own words and goal, source/time, current location when a licensed act may follow, known providers/services, relevant current plan, prior attempts, conflicts/unknowns, communication/accessibility needs, and why help is wanted now. A claim, old note, caregiver report, or model summary can identify a candidate need but does not establish the beneficiary's preference or a clinical conclusion.

Procedure.

1. Software presents known facts and asks the beneficiary or permitted caregiver to confirm/correct the need and desired result.
2. A clear authenticated description can complete framing without paid Puerto Rico L2 validation.
3. Puerto Rico L2 enters for requested human help, caregiver support, ambiguity, disagreement, distress, accessibility failure, required human service, or relationship work.
4. Clinical symptoms, medical suitability, behavior/safeguarding, or treatment questions route directly to the exact L3/U.S. medical clinician (L4)/outside provider (L5) professional; Puerto Rico L2 is not the gateway.
5. Duplicate work is linked rather than reopened; a distinct desired result remains separate.
6. Immediate safety uses the approved emergency/clinical route without full intake.

People and minutes. Clean direct description: 0. Philippine L1 objective contact/source repair: 2 / 5 / 10. Puerto Rico L2 human framing: 5 / 12 / 25. Clinical minutes belong to the protected receiving task.

Completion/failure/return. Complete with attributable plain-language need, desired result, provenance, unresolved facts, correct owning route, and first next step. “Coordinate care” alone is insufficient. Tests: direct clear request; vague caregiver report; duplicate need; distress; clinical symptom; inaccessible digital route; conflicting desired outcomes; immediate safety concern.

Additional coordination — identify the responsible person or organization#

When, purpose, and status. Identify an actor after the need and result are defined and before release or assignment. The purpose is to find who has both actual authority and practical ability to act. Section 5.5 supports cross-continuum coordination; Proxi's roster/directory search and acceptance control are design. Proxi cannot assign an external party unilaterally.

Decisive facts. Use the exact requested result, existing care-team and treating relationships, beneficiary choice, provider/service scope, current endpoints, location/jurisdiction for licensed acts, coverage/service-area/availability facts, relevant Participant roster, and required authority. Directory specialty, NPI, claim frequency, facility affiliation, or prior involvement alone does not prove current responsibility or acceptance.

Procedure.

1. Software searches current authoritative rosters and verified directories, separates identity from relationship, and shows possible actors with unknowns.
2. A clear existing contractual/clinical owner can be routed without Puerto Rico L2.
3. Philippine L1 verifies administrative identity, scope claims, endpoint, availability, and current relationship facts.
4. The beneficiary makes applicable provider/service choices directly when clear; Puerto Rico L2 enters only for D-021 support.
5. L3/U.S. medical clinician (L4)/outside provider (L5) identifies the clinically appropriate owner when clinical scope or responsibility requires judgment.
6. The proposed receiver must accept the exact obligation; acceptance is not performance. If no actor exists, record an explicit gap and safe continuing owner rather than a phantom “coordination team.”

People and minutes. Clean authoritative match: 0. Philippine L1 verification: 3 / 8 / 18. Puerto Rico L2 choice/relationship support: 0 / 5 / 15. L3 5 / 10 / 20 or U.S. medical clinician (L4) 8 / 15 / 30 only for clinical ownership judgment. External acceptance time is excluded.

Completion/failure/return. Complete with named canonical actor/external subtype, authority/scope basis, verified endpoint, accepted obligation, expected return, and backup/gap status. Tests: stale directory; same-name clinicians; external refusal; unknown location; no qualified provider; beneficiary selects alternative; care-team roster missing; owner accepts but does not act.

Additional coordination — gather and send what the recipient needs#

When, purpose, and status. Prepare and send only after the need, verified recipient, requested result, return route, and relevant permission facts are established. The purpose is to give the recipient the smallest usable packet. Section 5.5 requires coordination; packet minimization, source linking, and release evidence are Proxi design. O-021 classifies the packet; only a routine authorized-provider request/information instance may use the D-033 clean send.

Decisive facts. Bind exact beneficiary, recipient/current relationship, purpose, requested action/question, source-linked care-plan/record facts, beneficiary preferences, content/version, clinical author when applicable, channel/endpoint, permission and restrictions, timing, and expected response/reviewer. A prior successful fax, public directory, caregiver request, or portal listing does not authorize this disclosure or prove access.

Procedure.

1. Software reuses verified facts, includes originals where needed, exposes contradictions/unknowns, and runs the approved recipient-purpose-content-channel-permission-restriction rule.
2. Philippine L1 repairs objective packet/endpoint facts and prepares unchanged permitted resends.
3. Puerto Rico L2 confirms only actual relationship/permission ambiguity or performs substantive coordination under D-021.
4. L3/U.S. medical clinician (L4)/outside provider (L5) authors protected clinical meaning; Philippine L1/Puerto Rico L2 do not improvise it.
5. If the accepted O-021 rule classifies the packet as D-033 routine authorized-provider request/information, software sends with no extra human OK. Any genuinely required individual review occurs first. Mixed, special, new-clinical, Care Plan and other classes retain their own hold and reviewer; independent preparation and emergency-safe routes continue.
6. Track release, delivery, receipt/access, and response separately.

People and minutes. Clean preparation and a covered D-033 send: 0 human release minutes. Philippine L1: 3 / 8 / 18. Puerto Rico L2: 0 / 5 / 12. Clinical authorship L3 5 / 10 / 20 or U.S. medical clinician (L4) 8 / 15 / 30 only when needed. The existing 1 / 2 / 4 band applies only to an actually required separate human review. D-031 manual fallback is paid L1 courier work counted once.

Completion/failure/return. Complete only with exact packet/version, accepted class-rule result, evidence of any genuinely required review, recipient/endpoint, send/delivery evidence, and expected return. Tests: wrong recipient; changed endpoint; segmented behavioral record; stale plan; blocked release; resend; clinical question in packet; technical success/no receipt.

Additional coordination — obtain and route the response#

When, purpose, and status. Track after an authorized request or handoff creates a specific expected answer, artifact, acceptance, or action. The purpose is to close the communication loop without treating receipt as clinical interpretation. Section 5.5 supports follow-through; matching, reminder, and defect handling are Proxi design under O-004/O-019/O-020.

Decisive facts. Preserve outbound obligation, recipient/source identity, expected response, due condition, attempts, inbound event/artifact, patient/request/encounter match, document integrity, correction relation, response meaning as stated, and intended reviewer. A generic voicemail, unmatched fax, OCR summary, newest note, or “received” status is not the requested result.

Procedure.

1. Software matches acknowledgments/messages/documents to the exact request, suppresses duplicate reminders, and retains originals.
2. Clean matching/routing is zero-human.
3. Philippine L1 pursues administrative nonresponse or corrects incomplete, illegible, wrong-encounter, or endpoint defects; wrong-patient material invokes the privacy route.
4. Puerto Rico L2 enters only for actual beneficiary relationship, conflict, distress, accessibility, or requested warm follow-up—not as default tracker.
5. A clinical statement, instruction, dispute, or urgent cue routes unchanged to the exact authorized professional.
6. External refusal, no response, or partial result remains a truthful non-success/pending branch; it does not become an answer.

People and minutes. Clean tracking/routing: 0. Philippine L1 pursuit/repair: 3 / 8 / 20. Puerto Rico L2 triggered relationship recovery: 0 / 5 / 12. Clinical time is owned by the next task. Outside-party response time is excluded.

Completion/failure/return. Complete with matched source response or authorized truthful non-success, original artifact, defect disposition, accepted receiving actor/task, due/safeguard status, and next step. Tests: late response; duplicate response; wrong patient; partial answer; refusal; no response; clinical instruction to Philippine L1; corrected artifact after parent closure.

Additional coordination — obtain human clinical judgment when needed#

When, purpose, and status. Invoke only when the unresolved question requires nursing, behavioral/psychosocial, medical, diagnostic, treatment, prescribing, or other protected professional judgment. Section 5.5 and the RFA's dementia-proficient clinical capability support the branch; Proxi's narrow prepared task is design. Routine facts, scheduling, record retrieval, and status do not require clinical blessing.

Decisive facts. Deliver the exact question; current physical location and source/time; beneficiary goals/preferences; original records; relevant baseline, symptoms, function, behavior, medications, allergies, and prior decisions; literal conflicts/unknowns; prior actions; applicable timing; and the required return. AI extraction remains candidate data. Do not route by a vague “clinical review” label or use a regular RN for prescribing/medical authority.

Procedure.

1. Software/Philippine L1 assembles the source-linked packet and stops at judgment.
2. U.S. RN (L3) handles within-scope nursing/function/transition/safety assessment; U.S. behavioral clinician (L3) handles behavioral, psychosocial, caregiver-distress, or safeguarding judgment; U.S. medical clinician (L4) or applicable treating clinician handles diagnosis, treatment, prescribing, reconciliation, or higher authority.
3. The professional performs clinically necessary history/examination and records disposition, rationale, current instruction or limitation, safeguards, timing, and successors.
4. Unknown location/authority holds the licensed act while safe connection continues (CC-E43).
5. Missing evidence needed to decide today's question prevents a successful product. A future pending item receives a reviewer, timing, return route and safeguards; it does not erase a product already completed.
6. Puerto Rico L2 joins only for separate D-021 relationship support.

People and minutes. L3: 5 / 15 / 30+. U.S. medical clinician (L4): 8 / 20 / 40+. Puerto Rico L2: 0 / 5 / 12 only when separately triggered. Do not automatically stack roles or count an existing professional act twice.

Completion/failure/return. Complete with actual performer, location authority, sources, decision/disposition, rationale, safeguards, and returned successor tasks. Tests: administrative-only question; prescribing question sent to RN; unknown location; behavioral crisis; missing record with safe provisional disposition; conflicting clinicians; pending test; no available authorized clinician.

Additional coordination — tell the beneficiary the result#

When, purpose, and status. Return after a factual coordination outcome or attributable professional disposition exists. The purpose is to tell the person what happened, what changes or remains unchanged, who acts next, and what remains unknown. Section 5.5 supports communication; approved digital/asynchronous delivery, accessible rendering, and plan-back are Proxi design. Delivery is not understanding.

Decisive facts. Use the exact approved result/version/source, recipient/authority, beneficiary preferences, clinical author, unresolved facts, next actions/owners/timing, safe contact route, disclosure restrictions, and language/accessibility needs. Do not infer acceptance or comprehension from silence, portal access, voicemail, or a caregiver's presence.

Procedure.

1. Software can faithfully deliver a current approved factual status or already-authored explanation and capture authenticated questions/corrections.
2. Clear direct receipt and response can have zero paid Puerto Rico L2 minutes where the approved mode permits it.
3. The authoring L3/U.S. medical clinician (L4)/outside provider (L5) professional answers new individualized medical questions or performs an actual counseling duty; faithful approved delivery alone does not require another live clinician. Puerto Rico L2 adds no new clinical meaning.
4. Puerto Rico L2 enters for requested human help, caregiver support, distress, disagreement, accessibility recovery, substantive navigator work, or relationship-dependent coordination.
5. New clinical questions return to the author; a permission/authority gap holds only the affected disclosure. Preserve a proved faithful-delivery milestone while the new clinical question remains open; do not claim unresolved understanding or the new medical decision is complete.
6. Record understanding or its limitation without using a yes/no response as proof.

People and minutes. Clean approved digital/factual return: 0. Puerto Rico L2: 0 / 5 / 15. Authoring clinician explanation: 0 when same encounter; separate L3 3 / 7 / 15 or U.S. medical clinician (L4) 5 / 10 / 20. Philippine L1 technical delivery repair: 2 / 5 / 10.

Completion/failure/return. Complete with actual recipient, content/version, performer/mode, accommodations, questions/corrections, understanding result, and next action. Tests: factual digital success; clinical result needing author; voicemail only; interpreter need; distress; capable-beneficiary/caregiver conflict; stale result; new question.

Additional coordination — reflect and pursue the outcome#

When, purpose, and status. After a response, clinical disposition, beneficiary choice, or truthful non-success creates downstream work, return only the supported facts/results to the affected Care Plan, Ongoing, Medication, Referral, Assessment, 24/7, caregiver, or Care Coordination task. Section 5.5 supports continuing coordination; Proxi's source-preserving no-repeat handoff is design.

Decisive facts. Preserve the exact outcome/source/limits, beneficiary choice, professional author, effective time, plan effect or reviewed-no-change result, child obligations, owner acceptance, first required step, due/safeguard conditions, communication status, and unresolved dependencies. A note copy, handoff acceptance, owner assignment, or opened task does not prove downstream service completion.

Procedure.

1. Software maps only supported outputs to exact receiving tasks and links shared evidence/labor once.
2. Clean factual return and tracking are zero-human.
3. Philippine L1 pursues disconnected administrative successors.
4. Puerto Rico L2 performs only an actual requested/required person-facing return, caregiver support, distress/conflict/accessibility recovery, or relationship follow-through.
5. New protected content routes directly to the exact L3/U.S. medical clinician (L4)/outside provider (L5) professional and is counted there.
6. Care Plan changes use the Care Plan procedure; medication actions retain distinct professional, order, pharmacy, implementation, and monitoring milestones.
7. Apply only the applicability-aware O-019 route manifest; a completed clinical product remains complete while future monitoring/pending results continue.

People and minutes. Clean routing: 0. Philippine L1: 0 / 4 / 12. Puerto Rico L2: 0 / 5 / 15. Clinical time belongs to the exact successor. One conversation or professional act is never added once per credited service (D-016).

Completion/failure/return. Complete with sending/receiving task IDs, source-linked result, accepted receiver and first step, child status, person communication, and parent manifest. Tests: task accepted/not performed; update-all-pillars error; duplicate minutes; medication review without downstream order; unresolved external dependency; reviewed no-change; late correction after terminal; false parent closure.

Proposed timing and escalation#

Objective completion criteria#

Cross-pillar coordination feeds#

This SOP participates in cross-pillar episodes under 25_GUIDE_Eight_Pillar_Service_Integration.md. Care Coordination receives service attribution only for a returned outside response, working care handoff, completed transition obligation, or truthful unresolved external dependency that the correct owner reviewed and carried into ongoing care. A request sent, appointment booked, record received, or owner assigned is not the result by itself.

One provider call or transition conversation may satisfy several coordination tasks and feed several pillars. Count its shared preparation, call, and documentation minutes once; record later clinician, pharmacy, referral, or service-delivery acts once in their owning work.

Documentation and audit record#

The coordination record must show:

• trigger, route, identity, current location, beneficiary/caregiver participation, and applicable authority facts;
• source-linked facts and unresolved conflicts presented to each human reviewer;
• clinical question, clinician identity, credentials, beneficiary-location authority, decision, and rationale where clinical judgment occurred;
• exact recipient, purpose, approved content, channel, accepted class-rule authorization, evidence of any genuinely required human review, send time, and delivery/receipt/access evidence for every outbound PHI packet;
• every attempt, response, appointment, encounter, returned document, and reconciliation result without treating one as another;
• beneficiary choice, refusal, requested introduction, explanation, accessibility support, and teach-back result;
• care-plan and medication effects, pending-result ownership, follow-up assignments, and new linked work; and
• the route-specific successful or non-success outcome and the evidence supporting it.