Status: Semantic decision log; not operationally approved
Settled decisions#
| ID | Decision | Rationale/status | Review |
|---|---|---|---|
| D-001 | AI has no decision authority | Governing architecture | |
| D-002 | All action/routing/closure logic is deterministic and versioned | Replayability and safety | |
| D-003 | Clinical judgment remains with appropriately licensed humans | CMS and scope requirements | |
| D-004 | Philippine staff are administrative pursuit/preparation by default | Cost optimization with conservative compliance boundary | |
| D-005 | Philippine calls do not satisfy required GUIDE navigator contact | Conservative operating rule | |
| D-006 | No new outside-PCP portal is required | Minimize PCP friction; use existing exchange channels | |
| D-007 | V1 outbound PHI packets are human-released | Conservative existing product boundary, not a claim that CMS or HIPAA requires compliance-person review of every packet; exact release actors remain open by class | |
| D-008 | Prescribed, dispensed, possessed, reported-taking, and reconciled medication states remain separate | Medication safety | |
| D-009 | A referral closes only after returned documentation and plan reconciliation | CMS closed-loop requirement | |
| D-010 | Stable months should require effectively zero PCP action | Operating objective | |
| D-011 | Staffing is modeled from edge-case incidence and role-minutes | Avoid blended unsupported estimates | |
| D-012 | Proxi maintains, staffs, and furnishes every applicable GUIDE service in scope except respite; the Participant retains only nondelegable accountability and outside endpoints retain acts only they can furnish. This is full-package commercial capability and ownership, not a requirement that every beneficiary receive every service domain every month | Settled commercial service boundary from Leon, 2026-07-12; patient-level delivery remains needs- and cadence-specific | |
| D-013 | The default L2 workforce is a Puerto Rico-based nonclinical dementia care navigator with current Alzheimer’s Association® essentiALZ® certification for dementia care navigation, maintained current throughout each service year, at $22/hour all-inclusive; the navigator performs every permissible nonclinical human GUIDE act before licensed escalation | Settled workforce and cost boundary from Leon; certification does not confer clinical licensure | |
| D-014 | Proxi self-staffs 24/7 human first answer with a Philippines-based team that also performs interruptible administrative work between calls; Puerto Rico nonclinical care-team support and separate U.S. beneficiary-location-authorized clinical escalation remain available | Settled operating design from Leon; activation still subject to O-001 and the approved Partner Organization/offshore-PHI arrangement; clinical workforce boundary clarified by D-015 | |
| D-015 | The Puerto Rico L2 navigator operation performs no clinical or medical work, including when an individual navigator also holds an RN or other professional credential; every clinical or medical act routes to a separate U.S. clinical workforce and is performed by an RN, LCSW or other behavioral clinician, NP/PA/CNS, physician/MD, or other appropriately licensed professional who is authorized for the beneficiary location and the specific act | Settled workforce boundary from Leon, 2026-07-12; clinical labor and clinical minutes must never be labeled as Puerto Rico navigator labor | |
| D-016 | Count one actual human interaction or care action once in the labor ledger, while crediting every GUIDE service that the interaction's actual content separately furnished and objectively evidenced | Settled portfolio rule from Leon, 2026-07-12; GUIDE does not impose separate minutes for each service, but availability, a mention, or an opened task is not a furnished service | |
| D-017 | Human review follows the authority required for the specific act. The approved clean path proceeds without an added reviewer. Ordinary correction stays with the original performer and same-lane lead. A concrete system, software, billing, Medicaid, workforce, nursing-leadership, medical-leadership, or legal issue routes only to the real job authorized for that issue. No generic Quality, Privacy, Program, Operations, Data, or Compliance specialist is a beneficiary-case performer | Settled review principle from Leon, corrected 2026-07-15; compliance is not a universal approver and cannot approve a clinical act | |
| D-018 | Assessment work stops only where an unresolved fact is actually a dependency. A cheap eligibility pre-screen may avoid an obviously wasteful full assessment, but suspected dementia may proceed to the initial comprehensive assessment because that assessment is used to confirm dementia. If clinician attestation or another eligibility fact remains unresolved, alignment/PAAF and post-alignment work stay blocked while only independent, authorized, clinically useful, or safety-related work continues | Settled lane-and-spend rule from Leon, 2026-07-12, reconciled to current CMS assessment/alignment guidance | |
| D-019 | Proxi's caregiver-skills-training design is software/AI-led and human-owned: approved short video/text/voice material and bounded AI handle the main educational sequence and questions; a permitted L2 care-team trainer then conducts a focused, non-shaming plan-back or show-me touchpoint, corrects misunderstandings, confirms the caregiver's intended real-world use and help route, and records remaining needs | Settled operating design from Leon, 2026-07-12; CMS permits virtual training and specifies the provider route but does not expressly confirm AI-only completion, so compliance acceptance remains open under O-036 | |
| D-020 | Proxi schedules person-facing work to the applicable GUIDE contact cadence, but the person-specific service and expected beneficiary/caregiver result—not billing or a time target—determine the agenda and endpoint. Before proactive outreach, Proxi must name why conversation is appropriate now, what service will be furnished, what useful result the person should receive, and why their participation is needed. One primary navigator bundles applicable work, a naturally occurring qualifying interaction replaces redundant outreach, unasked domains remain unasked, and Proxi never creates a contact, medication reconciliation, care-plan revision, clinical review, education event, or other activity solely to fill a billing month | Settled member-burden and business-operating direction from Leon, clarified 2026-07-14; a stable required contact may furnish genuine person-led ongoing monitoring/support with one attributable person-specific outcome, while a month without an actual service receives no DCMP but does not by itself end alignment | |
| D-021 | Preference-sensitive and clinical work is prepared before the authorized human enters. Software/AI and lower-cost permitted staff retrieve, source-link, organize, preserve contradictions/unknowns, prepare options/tradeoffs or the exact clinical question, and draft the action packet. A beneficiary/caregiver may make a clear prepared choice directly; L2 enters for a required human service, requested help, ambiguity, disagreement, distress, warm introduction, relationship work, or valuable human confirmation. A beneficiary-location-authorized clinician performs clinically necessary history/examination and protected judgment, not routine record hunting, chart organization, form filling, scheduling, or chasing. Preparation never becomes AI decision authority and urgent/live-human service is not delayed | Settled business operating direction from Leon, 2026-07-14; applies to every task expansion and external-model adjudication | |
| D-022 | Reviewer-facing people resolve to the canonical employment and outside-party roster in 02_Roles_and_Escalation.md. Episode functions such as Care Plan owner, sending owner, receiving owner, trainer, coordinator, safety owner, or service owner are assignments performed by a canonical actor, not new roles. An unresolved authorized-performer decision may appear only as SOP DESIGN BLOCKED — NOT OPERATIONAL outside the performer list, linked to its controlling OPEN decision; it blocks activation of the affected branch while explicitly independent branches may continue and the draft may remain available for review. An unrecognized or unmapped person label is a phantom actor and blocks publication. No family, pool, department, function, or unresolved authority performs work. Corporate enabling roles are limited to real jobs—System Administrator, Software Engineering, Billing/Revenue Cycle, Medicaid Program Specialist, and HR/Workforce Administration—and enter only for their concrete work. Clinical/legal escalation is limited to the applicable same-lane lead, Head of Nursing/Clinical Operations, Chief Medical Officer, or Legal Counsel. Quality is a responsibility within those lines, not a separate universal actor. GUIDE Participant accountable authority is likewise only a family: an operational branch must name the actual retained or nondelegable act and the approved Participant body, role, or authorized individual that accepts it. An unresolved participant-authority assignment under O-PA-001 is a design blocker, not a performer. Software and work products remain in separate nonhuman lanes. Caregiver participation and decision-specific representative authority remain separate statuses even though they share one roster family | Settled semantic and reviewer-interface direction from Leon, corrected 2026-07-15; applies across every SOP and diagram | |
| D-023 | Proxi provides a permission-scoped digital companion with a configurable beneficiary interaction and caregiver view. It can deliver approved information, collect source-attributed self-reports, help with actions, accept a request for routed human follow-up, and ask an optional caregiver pulse. It prepares and routes existing GUIDE work; it is not continuous monitoring, emergency response, clinical review or assessment, synchronous human availability, guaranteed immediate human help, a ninth pillar, 24/7 human first answer, GUIDE human contact, caregiver assessment, one-on-one caregiver-support call, service completion, or payment evidence. A caregiver pulse remains caregiver-owned and may trigger routed review, but never becomes a beneficiary fact, burden diagnosis or score, urgency decision, completed assessment or support call, completed service, or payment evidence. Silence and stale or conflicting information remain unknown and never provide reassurance, including in Caregiver View | Settled product direction from Leon, 2026-07-14; activation mechanics remain open under O-061, but none of these exclusions is open for reversal there | |
| D-024 | Privacy and disclosure policy is approved before routine case execution and enforced deterministically in software. The approved matrix controls identity, permission, representative authority, recipient, content, purpose, minimum necessary, channel, expiry, revocation, suppression, and permitted disposition. AI may extract and prepare facts but never decides permission or disclosure. Missing facts route to L1 or L2 for permitted collection or clarification; verified facts that fit no approved rule hold only the affected act and open a bounded policy-governance question. The Privacy Officer does not routinely perform outreach, education, referral coordination, scheduling, relationship work, or repetitive clean-transaction approval | Settled operating direction from Leon, 2026-07-15; exact source-specific matrices and automatic-release classes remain open under O-008, O-012, O-014, O-021, O-030, O-057, O-058, and O-061 | |
| D-025 | Approved operational controls are enforced in software wherever the outcome is deterministic: roster eligibility, coverage, assignment acceptance, backup routes, route tests, deadlines, retry, callback obligations, required evidence, duplication, attribution, training-provider/format/language/accessibility matching, no-caregiver applicability, and safeguard routing. A failure creates the exact recovery action for the existing L1, L2, clinical, outside, or same-lane team-lead actor; it does not create a generic Program or Quality specialist. Human policy governance enters only for a mandated human review or a genuine policy gap | Settled automation-first operating direction from Leon, 2026-07-15; staffing, clinical, legal, and Participant-retained authority boundaries remain controlling |
D-009 predates the v0.2 distinction between successful specialist-loop completion and a truthful non-success terminal disposition. It remains controlling for a successfully completed specialist referral. O-019 must settle its scope for referrals that never produce an encounter and for non-specialist coordination before those paths can activate.
Open decisions#
| ID | Question | Owner | Status | Review |
|---|---|---|---|---|
| O-001 | Exact permitted offshore activities under the acquired Participant Agreement and CMS operating interpretation | Compliance/legal | OPEN | |
| O-002 | Final PR/US navigator geography and licensing model | Operations/compliance | RESOLVED by D-013; legal/contractual activation remains under O-001 | |
| O-003 | Final Care Plan and service-level clinical-authority design: per-element no-new-clinical-review, RN/LCSW, prescribing-clinician, and external-provider routes; the Participant-authorized whole-plan completion owner; and whether any additional plan-level clinical attestation has a required source and a concrete purpose beyond scoped attributable contributions | CMO/Participant clinical leadership/compliance | OPEN | |
| O-004 | Final urgency classes and response SLAs | CMO/operations | OPEN | |
| O-005 | PCP concurrence escalation clock for medication changes | CMO | OPEN | |
| O-006 | Effect of alignment on care-management billing by an outside PCP | Legal/billing; executed PA review | BLOCKED | |
| O-007 | Exact CEHRT access to Surescripts population medication data and events, not only UI display | Product/procurement | OPEN | |
| O-008 | Classify each outbound transmission after V1 by purpose, recipient, information category, controlling basis, mandatory reviewer if any, standard-protocol eligibility, exception triggers, release actor, and retained evidence; decide which approved classes may execute automatically | Product/compliance/privacy/legal | OPEN | |
| O-009 | Minimum evidence required to count each non-contact coordination action as a monthly GUIDE service, including legitimate purpose/need, actual action and outcome, actor/organization, substantive 24/7 events, deterministic execution with an external result, no-change outcomes, and the boundary between a furnished service and infrastructure, passive monitoring, AI analysis, reminder, failed outreach, or administrative pursuit alone | Compliance/billing | OPEN | |
| O-010 | Care-plan material-change taxonomy and thresholds, plus compliance-approved REVIEWED_NO_CHANGE outcome/evidence, that distinguish a new plan case/version from a documented no-change review without narrowing CMS revision requirements | CMO/care navigation/product/compliance | OPEN | |
| O-011 | Decision-specific capacity and representative-authority hierarchy, including required evidence, scope, expiry, conditional authority, and conflict handling | Clinical/legal/compliance | OPEN | |
| O-012 | Recipient- and channel-specific care-plan distribution satisfaction, failure, refusal, and authorized-exception standards | Compliance/privacy/operations | OPEN | |
| O-013 | No-caregiver safeguard package and any monitoring/contact cadence beyond the applicable current CMS minimum-contact requirements, by GUIDE tier and risk profile | CMO/care navigation/operations | OPEN | |
| O-014 | Which authorized role may release each class of V1 outbound care-plan packet and the conditions for Philippine VA re-send of an unchanged approved packet | Privacy/compliance/operations | OPEN | |
| O-015 | Exact care-plan content/applicability manifest and authorized exception classes beyond the public CMS minimum | CMO/compliance/product | OPEN | |
| O-016 | EHR commit/activation failure policy, downtime workflow, retry ceiling, and maximum safe delay while the prior version remains active | Clinical informatics/operations/product | OPEN | |
| O-017 | Care Plan service-gate rules and evidence for QUALIFYING, NONQUALIFYING, and NOT_EVALUATED_BLOCKED outcomes; no inference from case closure | Compliance/billing | OPEN | |
| O-018 | Annual assessment day-count convention, timezone/calendar anchor, boundary calculation, and compliance approval for implementation | Compliance/product | OPEN | |
| O-019 | Care Coordination case-kind and obligation model; successful and non-success terminal outcomes; route-specific closure manifests; and clarification of D-009 for no-encounter and non-specialist cases | CMO/care navigation/compliance/product | OPEN | |
| O-020 | Scope and evidence that satisfy the standing outside-PCP duties of GUIDE notification and meaningful current-plan access versus need-specific clinical coordination; specialist-referral PCP notice; active co-management consultation; reviewed-no-change evidence; and changed-PCP/in-flight handling | Care navigation/clinical/compliance/product | OPEN | |
| O-021 | Care Coordination disclosure and communication matrix: permission basis, packet content, exact human release role, channel-specific receipt/access evidence, requested-introduction requester eligibility/actor/modality and beneficiary conflict, and L1 preparation or re-send boundary | Privacy/compliance/operations | OPEN | |
| O-022 | Community-resource inventory ownership/freshness, the AAA/Tribal Aging Program agreement route, and the objective evidence that distinguishes sharing, referral, connection, intake, and service start | Care navigation/operations/compliance | OPEN | |
| O-023 | Medicaid HCBS applicability evidence, case-manager identity, required attempt/retry and continuing-monitoring policy, GUIDE/Medicaid service comparison, and gap/duplication responsibility outcomes | Care navigation/Medicaid operations/compliance | OPEN | |
| O-024 | Care-transition classification and minimum completion evidence; clinical-review triggers; linked completed medication outcome; proposed post-discharge contact timing; pending-test/result ownership; equipment/home-service, caregiver-capacity, accessible-instruction and teach-back requirements; rapid re-transition handling; exact RCC CMS-approval/compliant-arrangement predicate combinations; and PY2026 RCC/memory-care/hospice/long-term-nursing status handoff | CMO/care navigation/compliance/billing | OPEN | |
| O-025 | Care Coordination service-gate rules and evidence for QUALIFYING, NONQUALIFYING, and NOT_EVALUATED_BLOCKED, independent of case closure | Compliance/billing | OPEN | |
| O-026 | Medication case kinds, applicability, success and non-success terminal outcomes, route-specific closure manifests, no-change and incomplete outcomes, recurrence, and linked-successor policy | CMO/medication operations/compliance/product | OPEN | |
| O-027 | Medication event ontology and source-native evidentiary claims across request/order, transmission, pharmacy response, dispense/reversal, possession, reported use, administration, reconciliation, stop/cancel/disposal, including terminology identity, provenance, time, staleness, correction, and deduplication | Clinical informatics/pharmacy/product/CMO | OPEN | |
| O-028 | Prescribing-authority, RN, pharmacist, pharmacy-technician, collaborative-practice, L1/L2, and outside-provider taxonomy by credential, beneficiary location, jurisdiction, organization, and scope; plus the minimum medication-history and allergy dataset, source sufficiency, prescribing-clinician reconciliation product and attestation, no-change/completed/incomplete outcomes, monitoring responsibility, transition actor, and authorized exception policy | CMO/legal/compliance/medication operations | OPEN | |
| O-029 | Separate recommendation-sharing recipient and relevant-provider agreement manifests for GUIDE medication changes, including applicability, same-provider, multiple-provider, modification, disagreement, refusal, revocation, authenticated outside-order/emergency routes, beneficiary self-change/refusal, and nonresponse cases | CMO/legal/compliance/care coordination | OPEN | |
| O-030 | Medication regimen documentation and communication matrix across EHR, care plan, beneficiary, representative/caregiver, facility, schedule supports, pharmacy, and other clinicians, including clinical authorship, exact human release role, permission, accessibility, delivery, teach-back/comprehension evidence, destination-specific synchronization, supersession, revocation, and failure | CMO/privacy/compliance/product/operations | OPEN | |
| O-031 | Pharmacy execution and cancellation policy for technical acceptance, clinical clarification, preparation, handoff, partial/emergency/trial fill, transfer, substitution, shortage, claim reversal, and source-access limitations | CMO/pharmacy/clinical informatics/operations | OPEN | |
| O-032 | Medication safety-signal and adverse-event pathway: minimum source-faithful intake facts, beneficiary-location verification, approved clinical/emergency/poison-control destinations, 24/7 human handoff, urgency approval, failed handoff, causality boundary, nonclinical stop instructions, reporting, resumption, and closure | CMO/compliance/operations | OPEN | |
| O-033 | Separate CMS §7.5 schedule-support-information and ProxI medication-access-support catalogs, including applicability, independent outcomes/closure evidence, navigator and L1 boundaries, no-caregiver/facility routes, beneficiary or decision-specific authorized-representative choice, accessibility, and implementation assistance | Care navigation/CMO/operations/compliance | OPEN | |
| O-034 | Medication service-gate rules and evidence for QUALIFYING, NONQUALIFYING, and NOT_EVALUATED_BLOCKED, independent of medication-case closure | Compliance/billing | OPEN | |
| O-035 | Versioned medication clinical-review condition governance for high-risk medications, duplicate therapy, interactions, dose, labs, renal/hepatic facts, and other CDS signals, including primary clinical sources, input/unknown policy, approval, and test requirements | CMO/pharmacy/clinical informatics | OPEN | |
| O-036 | Confirm that the D-019 software/AI-led, permitted-human-owned training route satisfies the executed Participation Agreement and current GUIDE interpretation; approve the exact completion evidence, permitted trainer/vendor roster, group-participant evidence, and topics requiring observation or qualified instruction. AI-only completion is not proposed | Compliance/care navigation/product; executed PA review | OPEN | |
| O-037 | Whether the standard GUIDE model explanation and documented consent discussion may be completed digitally or by bounded text/voice AI on the clean path, including required evidence of comprehension and the triggers for a human conversation | Compliance/legal/care navigation/product; executed PA review | OPEN | |
| O-038 | Which commercial delivery model Proxi will sell—software platform, managed navigation, or full managed service—and which navigator, VEA, education, program, billing, compliance, and clinical roles are included in each package | Executive/operations/product/finance | RESOLVED by D-012 | |
| O-039 | Accept or replace the revised human-workload assumptions in 22_GUIDE_Human_Workload_and_Staffing_Estimates.md, including tier/caregiver/RCC mix; proposed 8/15/25-minute stable brief/ordinary one-need/extended nonclinical direct-contact range and 5/10/15-minute focused second individual-tier contact; replacement or reconciliation of the existing 20/25-minute total active-navigator envelopes so preparation, documentation, and actual follow-through are not hidden or truncated; 74-minute authorized clinical-support pool; 106-minute higher-clinician pool; the Care Plan zero-incremental, one-RN, one-LCSW/behavioral, one-higher-authority, and multi-clinician case shares, between-event question rate, and per-contribution minutes; first-year add-ons; productive utilization; the Philippines coverage roster; program overhead; and pilot caseload. Every subtotal must use the same actual aligned-life denominator for shared coverage and fixed overhead—the retired 746-minute headline mixed a 5,000-life Philippines allocation with a 500-life program allocation | Operations/finance/product/clinical leadership | OPEN pending field data | |
| O-040 | Verify each proposed worker's actual Alzheimer’s Association® credential issue and expiration dates and any separate professional licenses. The role-level credential is settled as current essentiALZ® certification for dementia care navigation; it does not confer clinical authority | Operations/compliance/credentialing | RESOLVED at role-design level by D-013; individual credential verification remains an onboarding control | |
| O-041 | Which Care Plan explanations, option comparisons, confirmations, refusals, and choices may use bounded text, video, text-chat, or voice AI on the clean path; the required identity, exact-content, accessibility, correction, comprehension, voluntariness, and audit evidence; and the triggers for L2, interpreter, privacy/legal, or clinician involvement | Care navigation/compliance/legal/product/clinical | OPEN | |
| O-042 | How caregiver-originated sensitive information is stored, attributed, restricted, summarized in beneficiary-facing care-plan content, and routed when a caregiver requests confidentiality but the information may affect safety or care | Privacy/legal/clinical/care navigation | OPEN | |
| O-043 | Supported Care Plan languages, formats, and accessibility modes; fidelity and usability evidence; and the exact conditions requiring a qualified interpreter, translator, accessibility professional, or clinician review | Care navigation/compliance/accessibility/clinical/product | OPEN | |
| O-044 | Evidence that a software-generated Care Plan service or provider option set used the beneficiary's confirmed constraints, disclosed inventory scope, freshness, unknowns and exclusions, avoided sponsored or unexplained default ranking, and returned a truthful no-match result; coordinated with community-inventory decision O-022 | Care navigation/compliance/product/operations | OPEN | |
| O-045 | Approve Proxi's concrete organizational roster, coverage, and escalation assignments for System Administration, Software Engineering, Billing/Revenue Cycle, Medicaid operations, HR/workforce administration, Philippine L1 leadership, Puerto Rico navigator leadership, Head of Nursing/Clinical Operations, Chief Medical Officer, and Legal Counsel. For each real job, specify the observable trigger, source of authority, named accountable leader, coverage and backup, response target, exact output, return recipient, and portfolio-versus-beneficiary boundary. Do not recreate generic Program, Quality, Privacy, Operations, Data, or Compliance case specialists. Reconcile retained release or Participant acts separately with D-007, O-008, O-012, O-014, O-021, O-030, special restrictions, and the executed Participation Agreement | Operations/clinical leadership/legal/billing/HR/product | OPEN | |
| O-046 | Approve Proxi's pre-alignment spend policy for suspected dementia and unresolved eligibility: the minimum clinician-led diagnosis-confirmation work, which expensive assessment portions may be deferred, when the staging tool starts the 60-day clock, and the conditions for resuming the full assessment; reconcile with the executed Participation Agreement and current PAAF instructions | CMO/compliance/program operations/finance | OPEN | |
| O-047 | Determine whether completing an overdue tier-required touchpoint permits retroactive DCMP billing for earlier months that contained an otherwise qualifying service, or restores billing only prospectively; obtain the executed Participation Agreement rule or written CMS/Help Desk direction before releasing such claims | Billing compliance/program operations/legal; executed PA or CMS confirmation | OPEN | |
| O-048 | For a Care Plan element awaiting an outside PCP or specialist response, approve the number and spacing of pursuit attempts; identify which element types a beneficiary-location-authorized GUIDE clinician may resolve within that clinician's own authority; identify which must remain open with a safe current course and named follow-up; and define the beneficiary communication. Medication-change concurrence remains governed by O-005 | CMO/care navigation/compliance | OPEN | |
| O-049 | When a late or corrected result clinically contradicts Care Plan content already distributed, define the affected recipients, the professional who sets correction urgency, the permitted communication/release actors, and the evidence that every required correction was delivered or truthfully remains unresolved | CMO/privacy/compliance/operations | OPEN | |
| O-050 | Define the consequence of a sustained authenticated refusal of required-cadence contact for tier compliance, DCMP claims, and alignment; the lower-burden alternatives that must be offered; whether a permitted caregiver-only route may satisfy cadence during beneficiary refusal; the required evidence; and when refusal-driven no-service months approach the claims-based unalignment condition. Requires the executed Participation Agreement or written CMS direction | Compliance/billing/program operations/care navigation | OPEN | |
| O-051 | Approve the early transition-recovery ownership and workload split: Puerto Rico navigator performs the nonclinical recovery conversation; separate beneficiary-location-authorized U.S. clinicians perform symptom interpretation, urgency/disposition, medication reconciliation, treatment, and other clinical acts; establish event incidence and low/ordinary/high minutes without double-counting the transition clinical family | CMO/clinical operations/care navigation/finance | OPEN | |
| O-052 | Before marketing or pricing each optional enhanced commitment, approve its occurrence assumption; low/ordinary/high minutes by role; funded Proxi owner; protected professional act and authority; external partner/service-area capacity; who pays; truthful completion outcomes; and whether the offer is Proxi-furnished or referral-and-closed-loop coordination | Product/operations/finance/CMO/compliance | OPEN | |
| O-053 | Approve the beneficiary-journey ownership defaults: when the primary navigator is assigned and introduced; who owns person-facing status during a material CMS waiting period; who owns the welcome contact; and who owns the person-facing goodbye/continuity conversation during transfer or exit | Program operations/care navigation/compliance | OPEN | |
| O-054 | Approve and fund after-hours clinical coverage before the 24/7 clinical-response promise activates: clinician type, beneficiary-location licensure coverage, response expectation, backup, maximum concurrent demand, failed-connection disposition, and how the clinical event is counted once | CMO/clinical operations/finance/compliance | OPEN | |
| O-055 | Approve the reasonable-attempt standard for required contacts: attempts and spacing by cadence/tier, preferred and alternate channels, accessibility and interpreter handling, wrong-contact/no-safe-message cases, when the contact becomes overdue, when the original worker's same-lane lead performs reassignment or recovery, and how attempt labor is counted without contact or service credit | Care navigation/operations/compliance/billing | OPEN | |
| O-056 | Approve the AI-on-call participation policy by participant location and call type: disclosure and affirmative permission before AI listens, transmits, whispers, transcribes, records, translates, or summarizes; who may grant permission for whom and for which act; retained permission evidence; whether any pre-permission non-PHI IVR/menu handling is allowed; treatment of withdrawal and its prospective versus retrospective effect; when a static checklist or human-only route is required; BAA/vendor/security/model-use/subprocessor/offshore-access controls; exact retained artifacts; and retention, deletion, access, and correction rules | Privacy/legal/compliance/security/product | OPEN; the working national clean path is all-participant disclosure and affirmative permission, not a claim that every jurisdiction has the same rule | |
| O-057 | Approve every outbound-call class before activation: live human, autodialed, prerecorded, AI-generated voice, voicemail, reminder, emergency, health-care exemption, informational, or telemarketing; required prior express or written consent, approved exemption, identity/disclosure/callback language, local-time and frequency rules, opt-out/revocation handling, suppression propagation, and retained evidence | Legal/privacy/compliance/operations/product | OPEN; no health-care exemption is presumed merely from the topic | |
| O-058 | Approve the source-by-source external-data access matrix for GUIDE reports/PAAF, HETS, Blue Button, payer APIs, EHR FHIR/USCDI, HIE/TEFCA, ADT, e-prescribing/medication history, provider directories, and community inventories: entity entitlement, contract/enrollment, patient authorization, permitted purpose, query frequency, provenance, staleness, correction, retention, downstream reuse, and prohibited inferences | Product/security/privacy/legal/compliance/clinical informatics/program operations | OPEN; no feed activates from semantic usefulness alone | |
| O-059 | Approve and fund the AI-to-human takeover service levels: staffed hours, concurrency, language/accessibility coverage, role-specific response expectations, maximum safe hold, context-packet contents, the no-transcript and human-only takeover path when AI listening/transcription/retention/continued processing was declined or withdrawn, warm-transfer failure behavior, Philippine shift-lead recovery, System Administrator or Software Engineering incident routing when the technology fails, separate clinical/emergency transfer, and the evidence that the person did not have to restart the story | Operations/care navigation/clinical operations/product/finance | OPEN | |
| O-060 | Choose the commercial treatment for pooled 24/7 human coverage and program overhead at sub-scale panels: launch surcharge, sharing a real staffed roster across contracted Participants/customers, minimum launch panel, or deferred self-staffing; state the panel/concurrency thresholds that force a new seat or re-estimate; and prohibit pricing from a mechanical 5,000- or 10,000-life divisor when those lives do not actually share the capacity | Finance/operations/compliance/executive | OPEN; Manual 22's pooled cells are planning illustrations, not approved prices | |
| O-061 | Approve the Daily Companion and Caregiver View activation mechanics: default and maximum cadence; beneficiary and caregiver opt-in/withdrawal; identity and permission scope; visible data and source/as-of presentation; caregiver-owned sensitive information; accessibility and channels; no-response, stale-data, and conflict presentation; interaction burden; AI/call participation and retention; routed-human-request and stop-candidate response levels; and implementation evidence that enforces D-023 | Product/privacy/legal/compliance/care navigation/clinical operations/security | OPEN; activation controls only. D-023 exclusions from monitoring, assessment, human contact, service completion, and payment evidence remain settled and are not reopened here | |
| O-PA-001 | Obtain and cross-check the acquired Participant's executed GUIDE Participation Agreement and appendices before activating PA-dependent rules. For every claimed Participant-retained or nondelegable act, identify the controlling provision, exact act, approved Participant body or role, authorized individual-assignment and acceptance rule, required output, return actor, due-time rule, backup or continuity route, and explicitly independent work that may continue. Until both the controlling provision and performer assignment are approved, the affected branch is SOP DESIGN BLOCKED — NOT OPERATIONAL; no abstract GUIDE Participant accountable authority or unresolved participant-authority row may perform work | Compliance/legal | BLOCKED -- controlling document not present |
Change proposal template#
Proposal ID:
Affected decision/rule/SOP:
Current position:
Proposed change:
Evidence:
Operational impact:
Clinical/compliance impact:
Cost impact:
Required approvers:
Disposition: