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 retain the conservative human-release default outside D-033's two approved-rule automatic provider classes. For an ordinary nonclinical community referral, the assigned Puerto Rico GUIDE navigator performs the final 1–2 minute release check and authorizes the exact person-specific packet or Proxi-led warm introduction; a designated Puerto Rico navigator lead performs the same bounded act as the preapproved backup. Software/AI and Philippine L1 may prepare and validate the packet but may not release it. Any protected clinical judgment, authorship, order, or instruction is completed first by the applicable beneficiary-location-authorized U.S. clinician; the navigator does not review or alter clinical substance. For that ordinary community class, each corrected, changed-destination, or resent V1 disclosure receives a new exact release event. D-033's covered clean sends need no extra human releaser; other actually required release performers remain open under their class-specific decisions | Settled ordinary nonclinical community-referral operating rule from Leon, 2026-07-16; conservative product boundary, not a claim that CMS or HIPAA requires human review of every release 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, HR/Workforce Administration, and the narrowly delegated Administrative Manager under D-027—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-026 | The standing 24/7 access roster is staffed by Philippine nurses acting in the nonclinical L1 first-answer capacity. Public RFA Appendix B §3.1 permits a human third-party helpline; it does not expressly require an around-the-clock clinical helpline, Proxi-employed clinician, or Puerto Rico shift. Do not derive such staffing from the existence of the access duty. Substantive caregiver support remains a direct care-team act under §§3.2/8.3.4; Philippine nonclinical care-team membership and permitted support acts must be established under O-001 before that lane may furnish the separate service. Clinical judgment goes to the exact actual-clinical-subject-location-authorized professional when needed, through an approved route and response policy; emergency-safe work is never postponed for ordinary hours. Cost additional Puerto Rico or clinical availability only for an actual controlling requirement or a deliberately chosen service promise, with the hours, scope, backup and funding explicit. Public §3.1's explicit third-party allowance is off-duty; acceptance of Proxi's proposed all-hour structure, actual on-duty membership or written arrangement, and an operational required sharing route remain O-001/O-008/O-PA-001 before launch. This is not a new clinical-shift mandate. D-005 and D-015 remain controlling | Settled staffing direction from Leon, 2026-10-03; public source rechecked the same day. Clarifies D-014 without authorizing offshore care-team membership, clinical practice, unapproved callbacks, or release | |
| D-027 | A designated Proxi Administrative Manager gives final business approval for a new partner contract or a change to the services or coverage area Proxi commits to furnish. Software and existing staff prepare the terms, costs, capacity, scope and restrictions. The manager returns an attributable approval/refusal, effective date, conditions and implementation recipient. This is a real corporate job added to the canonical roster, not a routine beneficiary-case reviewer. The designation does not itself grant clinical judgment, legal interpretation, CMS approval, reporting-attestation, signing or Participant-retained authority; each such act requires its own actual authority | Settled business-approval choice from Leon, 2026-10-03; implements his answer rather than inventing a program/compliance owner | |
| D-028 | Proxi's residence-visit model uses a paid outsourced social worker or home-safety specialist physically at the beneficiary's current residence, plus a Proxi clinician participating through telehealth for the assigned clinical assessment. The onsite worker supplies qualified structured observations and nonclinical context, not unlicensed medical judgment; the clinician performs the actual nursing/behavioral/medical act within instrument, jurisdiction and modality authority. The onsite worker must be an approved interdisciplinary-care-team member through the actual paid employment/Partner arrangement; remote participation alone never satisfies a required onsite visit. Reuse clinical work across the shared visit/assessment rather than adding a second generic review. Price onsite work and travel/contract fee separately from PR L2; actual partner, qualification, clinical assignment, fee and backup remain O-039/O-PA-001 | Settled delivery direction from Leon, 2026-10-04; public RFA §1.3 permits a care-team visitor and remote participation by other members, but this design does not itself approve a vendor, every telehealth procedure or an absent Agreement term | |
| D-029 | The settled Puerto Rico navigator $22/hour all-inclusive cost applies to every scheduled paid hour, including downtime and training—not only delivered active case work. Use the existing paid-work-hours/load model consistently for capacity and payroll. Training, replacements/turnover and other shrinkage are counted once: if already included in the productive-utilization allowance, do not add them again; otherwise deduct/add their actual paid time explicitly. The $22 amount and this payout basis do not validate the utilization, turnover or caseload inputs | Settled direct clarification from Leon, 2026-10-04; preserves his observation that work hours and load were already modeled, while connecting paid-hour cost to that model | |
| D-030 | Routine human help during CMS waiting, welcome after alignment and transfer/goodbye is allocated by act: Philippine L1 performs factual/logistical help; Puerto Rico L2 performs relationship, distress and required navigator work. Approved software handles clear routine updates without creating a human task. Do not add a navigator visit merely because an administrative message exists; combine an actual required/valuable introduction or continuity act with a natural contact where appropriate. This does not grant PH/PR clinical, legal, unsupported release, CMS signing or business-commitment authority; protected acts retain their own licensed/authorized person. It does not create a continuous PR shift or settle the exact primary-navigator assignment/intro timing | Settled direct selection from Leon, 2026-10-04; resolves the per-act human division in O-053 without inventing an enrollment/programme worker | |
| D-031 | When permitted automated transmission is unavailable, Philippine L1 support manually sends (a) an already-approved care-coordination request/information packet to its authorized provider and (b) a clinician-approved medication recommendation to the already-selected relevant PCP/specialist. The worker uses the permitted channel and records the actual send/delivery/failure, with factual receipt pursuit for coordination. The payload, recipient, purpose, permission and any required human release authorization must already be valid. This is administrative transport, not clinical interpretation, authoring/changing a recommendation, choosing clinical recipients, resolving provider agreement, prescribing or giving a new order to the patient. Actual clinical disagreement/question uses the existing professional route; clear attributable facts do not create a duplicate clinical review. Clinical authorship, human release authorization and physical transmission remain distinct. D-007 community-referral release, O-014 Care Plan sending/release, all other O-021/O-030 classes and O-001 offshore acceptance are not granted by this choice | Settled direct answers from Leon, 2026-10-04, naming Philippine support for the two expressly bounded manual provider-packet sending tasks | |
| D-032 | The family first meets its accepted assigned PR navigator during initial assessment/care planning, within a genuinely useful existing planning/support conversation. Explain the named primary contact, working help route and next useful action; state pending CMS alignment honestly. No extra welcome call, new clinical encounter, routine RN/L2 gate before medical-only work or continuous PR shift is created. Record actual introduction time once within its parent work; an introduction alone does not prove assessment/planning completion, a qualifying navigator contact, alignment or payment. Actual individual/coverage/backup acceptance and contact/mode/evidence requirements remain O-053/O-063/O-064/O-PA-001 | Settled direct answer from Leon, 2026-10-04: during initial assessment/planning, not after final CMS alignment as a separate requirement | |
| D-033 | Routine requests/information to an authorized provider and unchanged medication recommendations already approved by the US clinician send automatically when approved deterministic sharing rules permit the exact subject, content, selected recipient, purpose, channel, lawful basis and restrictions. No extra human OK is required merely for a first packet or covered clean resend. Clinical approval alone is not sharing permission or provider agreement; AI never decides either or selects the clinically relevant recipient. A genuinely source/law/contract-required case-specific human review is completed by its actually authorized performer before sending; missing, conflicting or uncovered facts hold only the affected act. D-031 Philippine support remains the manual courier when automation is unavailable, with actual work counted once. Care Plans, ordinary D-007 community referrals, patient orders/counseling, new clinical meaning and special/uncovered classes retain their own requirements. Independently due clinical work is not waived. This is the narrow company policy choice, not field activation, approved legal/class rules or an accepted contract/Agreement | Settled direct answer from Leon, 2026-10-05: automatic when approved rules allow it; narrows the general D-007 first-packet default only for the two named provider classes |
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#
Outbound approval interpretation. D-033 selects automatic approved-rule sending only for routine authorized-provider requests/information and unchanged US-clinician-approved recommendations to the selected PCP/specialist. No extra human OK is added merely because it is a first packet. Clinical authorship, lawful disclosure basis/restrictions, any genuinely required case review, transport and provider agreement remain separate. Care Plans, D-007 community referrals, patient orders/counseling, new clinical meaning and special/uncovered classes keep their own requirements. This company choice does not prove an accepted class matrix, legal/contract/BAA/delegation facts or field implementation. Hold only the send whose actual required facts or authority remain missing.
| ID | Question | Owner | Status | Review |
|---|---|---|---|---|
| O-001 | Exact permitted offshore activities under the acquired Participant Agreement and CMS operating interpretation, including the Philippine nurses' nonclinical third-party first-answer capacity; the accepted on-duty versus off-duty coverage basis (actual care-team first-answer membership, written acceptance of all-hour third-party coverage, or a funded accepted on-duty care-team arrangement), including each period's hours, scope, paid performer and backup; whether and on what evidence they may also be approved interdisciplinary care-team members for specific nonclinical caregiver-support acts; required training, assignment, privacy and Partner Organization terms; and which acts remain with another approved care-team member. Do not infer U.S. clinical authority or formal navigator-contact qualification from Philippine nursing licensure | Legal/Participant contracting and actual care-team leadership | 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 authority: exact no-new-clinical-review, RN/behavioral, prescribing and outside-professional routes; the approved whole-plan completion mechanism; whether a case-specific human completion review/signature is actually required by the executed Agreement, law or explicit Proxi policy; and, only if required, its actual performer, act, output and backup. Identify the controlling provision or design purpose before calling it Participant-retained/nondelegable. A clinical attestation needs a concrete professional purpose beyond re-signing already sufficient scoped contributions | CMO/Participant clinical leadership/legal/operations | 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 by purpose, recipient, information category, lawful basis/restrictions, source-required review, approved-rule eligibility, actual human reviewer only if required, exception triggers and retained evidence. D-033 settles automatic approved-rule sending for only routine authorized-provider requests/information and already-clinician-approved recommendations to selected PCP/specialist, without an extra per-packet OK; actual matrix/contract/delegation and restricted-case acceptance remain open. Care Plans, D-007 community referrals, patient orders/counseling and special/uncovered classes retain their own requirements. For the Access interaction record, resolve off-duty public sharing versus Proxi's conservative accepted-daytime all-call sharing, direct care-team internal records, unavailable attestor, caregiver-sensitive partitions, actual paid release/receipt/acceptance and correction paths. The selected third-party helpline cannot launch with a permanently blocked mandatory sharing route; independent emergency-safe work continues | Actual communication-policy/Legal authority for its requirement; product for accepted rule implementation | PARTIALLY SETTLED under D-033; actual class/authority/exception acceptance 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 Distinguish professional product, coordination-parent outcome and downstream child result; missing prerequisite evidence prevents today's successful product, while a future result/monitoring obligation does not erase one already completed. Apply only the route-specific current/due manifest, not a universal all-children-finished test. | 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 Resolve the RFA summary's as-needed referral language versus Appendix B §5.2 may language; define current referral-basis and substantive same-question PCP-consultation reuse evidence without forcing a new clinician act; preserve shall PCP notice, should active-co-management consultation, may specialist notice/plan sharing and must returned documentation/plan changes. | Care navigation/clinical/compliance/product | OPEN | |
| O-021 | Care Coordination disclosure and communication matrix: permission basis, packet content, approved automatic class or actually required human review, channel-specific receipt/access evidence, requested-introduction requester eligibility/actor/modality and beneficiary conflict, and L1 preparation or re-send boundary. D-033 selects approved-rule automatic sending of routine provider requests/information with no extra first-packet OK; any genuinely mandatory human review still precedes sending. D-031 settles Philippine L1 as the manual provider-packet transmitter when automation is unavailable, only after approval/permission and any required human release; it does not grant sharing authority, select an otherwise-required reviewer or cover other communication classes | Actual communication-policy/clinical/Legal authority for its requirement; L1 for the settled manual transport act | PARTIALLY SETTLED under D-031/D-033; actual class/permission/restricted-review/evidence acceptance OPEN | |
| O-022 | Community-resource ownership/freshness and actual Proxi priority/usability/technical jobs; geography/population-specific direct, written AAA/TitleVI or combined route and actual Partner/party/assistance/return/payment terms. Distinguish resource sharing, navigator referral/initiation, D-007 release, connection/assistance, intake, actual first use and usefulness; the Proxi start-evidence design is not CMS's sole definition of connection, and local outcome is not monthly qualification. Exact retained approval requires a controlling basis/person, not an inferred Participant selector. Actual company commitment uses D-027; signing is separate O-066/actual party authority | Care navigation/operations/compliance | OPEN | |
| O-023 | Medicaid HCBS eligible-AND-currently-receiving evidence, actual programme/case-manager responsibility, genuine contact/attempt/retry and continuing-monitoring policy; standard no-PHI information versus D-007 ordinary referral versus other PHI coordination/clinical/special-data classes. Accept actual asynchronous versus live substantive joint-review mode, each side's current source/confirmation and finding authority; preparation/source ingestion alone is not completed §6.2 review. Separate factual candidate gaps from programme decisions, clinical equivalence/safety and GUIDE payment integrity; actual authority/accepted responsibility/decline/nonresponse and continuing work remain distinct, no guaranteed outside cooperation or blanket L2/clinical validation | 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: the public PMP §2.12 60-day trigger is unapproved AND no compliant arrangement; approved/arranged uses the ordinary route, while approved/unarranged and unapproved/arranged have no express 60-day grant and require the executed Agreement or written CMS disposition. Reconcile the FAQ's ordinary pre-delivery prerequisites with the §2.12 Participant transition permission; distinguish Participant services from the unapproved RCC delivering as Partner; and PY2026 RCC/memory-care/hospice/long-term-nursing status handoff Separate source prerequisites needed for today's clinical product from future pending results with accepted reviewer/timing/return/safeguards. Decide whether the proposed 48–72-hour recovery contact is universal, risk-triggered or a selected commercial promise, and distinguish Proxi factual follow-up from an AHRQ RED-like clinical-staff call. | 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 and applicable success/non-success outcomes; separate M14/M15 professional product, M16/M29/M30 explanation/communication, applicable change/pharmacy execution and each due M31 monitoring obligation; missing prerequisite data versus future monitoring; parent closure, truthful refusal/withdrawal/unresolved outcomes, recurrence and linked-successor policy. No completed clinical review is erased merely because a later obligation is open, and a review alone does not complete a change episode | 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 sharing and agreement-provider manifests for GUIDE medication changes; reuse of a current professionally established provider basis versus unresolved clinical applicability/responsibility; same/multiple-provider cases; modification, disagreement, refusal and revocation; outside-order/emergency routes; exact nonresponse/factual correction; early interest/refusal versus final choice; withdrawal versus a still-current sharing duty; lawful order issuance versus choice before active non-emergency instruction/implementation and any explicitly adopted stricter sequence | CMO/legal/compliance/care coordination | OPEN | |
| O-030 | Medication documentation/communication matrix for each EHR, Care Plan, beneficiary, representative/caregiver, facility, schedule-support, pharmacy and clinician destination: clinical authorship; approved automatic-release class and any actually required human reviewer/authority; approved faithful digital/asynchronous explanation versus actual individualized/live clinical act; permission/accessibility/delivery; beneficiary/helper plan-back versus professional/facility receipt or order/MAR incorporation; destination-specific synchronization, supersession, revocation and failure. D-033 selects approved-rule automatic sending of unchanged clinician-approved recommendations to the selected authorized PCP/specialist without an extra per-packet OK; clinical approval alone does not establish permission and any genuinely mandatory review remains required. D-031 settles Philippine L1 manual transmission of an already clinician-approved recommendation to its selected authorized PCP/specialist when automation is unavailable; it does not appoint the human release authorizer, decide provider agreement or cover patient orders/counseling/other destinations. No mandatory live clinician counseling for every proposal or guessed nonclinical release performer is approved by the public RFA | Actual clinical/communication-policy/Legal authority for its requirement; L1 for the settled manual provider-recommendation transport | PARTIALLY SETTLED under D-031/D-033; actual class/mode/destination/restricted-review/authority acceptance 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 D-019's software/AI-led, permitted-human-owned route against the actual Agreement/current GUIDE interpretation. Approve topic/format-qualified trainer and paid-provider arrangements; permitted delivery versus application versus later usefulness versus monthly service evidence; accessible verbal plan-back and safe voluntary/simulated show-me; partial/declined/deferred/remediation results; group participant evidence; exact protected acts and paid-time/fee capture. No CMS quiz, clinical blessing, universal live patient demonstration or 20-minute stop is inferred. AI-only completion is not proposed; actual Philippine teaching/support requires O-001 | Actual care-team/navigation, clinical-scope and Participant policy authorities; 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 Manual22's explicit workload inputs: actual tier/exposure/caregiver/RCC mix; current total-active episode bands and contact/annual-plan bundling; deduplicated nonclinical, caregiver and scoped clinical event reach/frequency/contributions; first-assessment versus actual first-horizon annual events; D-028 paid field act, documentation/travel/fee and nonadditive shared clinical work; PR 160 scheduled paid hours/month at provisional 70% productive load connected to D-029's paid-hour $22 cost; learning, handover/replacement and paid overlap counted once; PH 24/7 roster shrinkage/reserve/lead, concurrency and actual covered pool; per-Participant/shared/employee/claim/partner program drivers and multiplicity; actual quotes, payout units, availability and candidate extras. Different real cost pools may have different cohorts; never silently divide ten Participant-specific program blocks as if only one existed. Current scenario and mathematical capacity are planning inputs, not approved price, clinical incidence or pilot caseload | Operations/finance/product/clinical leadership | OPEN pending actual contracts, cost/rate basis and cohort 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 | Approve the specific direct Care Plan explanation, comparison, confirmation, correction, refusal and choice modes and their identity, exact-content, decision-authority, accessibility, understanding, voluntariness and retained-response evidence. Separate a beneficiary's human decision from Proxi-paid human work; specify actual L2/interpreter/clinical/legal entry conditions and any independently required human planning/contact act. D-021 controls avoidance of a routine L2 blessing, but does not itself approve every digital/AI mode or AI-only whole-plan delivery | Care navigation/legal/product/clinical/Participant operating authority | 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 and caregiver-education/training languages, formats, and accessibility modes; fidelity/usability evidence and safe accessible plan-back/show-me alternatives; and the exact conditions requiring a qualified interpreter, translator, accessibility professional, or clinician review | Actual navigation, clinical-content and qualified accessibility authorities; caregiver method/provider acceptance remains O-036 | 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, the Administrative Manager's narrow D-027 business scope, 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 | For each optional additional promise, record its exact baseline interface and distinct added result; selected Proxi-furnished paid act versus coordination-only; actual accepted individual/contractor, current subject/location/provider/act/scope/modality and instrument/population/state-source fit; responsible professional component/return and backup; service-area capacity; who pays, actual occurrence and low/ordinary/high incremental minutes/fee/travel/availability; approved additional cadence and truthful declined/deferred/unavailable/non-success/withdrawal result. Required GUIDE work, accessibility and human access remain independent; no free Participant worker or inherited annual-minute budget. Manual20 recommends combined practical caregiver coaching, targeted wandering preparedness and meaningful activity participation for owner choice, not activation; all twelve groups remain visible. Aligned patients cannot be charged for GUIDE services; an enhancement label creates no payment authority. Source-fit limits include pain tool, wandering/disclosure/egress, U.S. planning/state forms and swallowing/therapy components. Defined digital/protected sub-acts do not approve field delivery or AI-only GUIDE completion | Designated Administrative Manager D-027 for company commitments, actual clinical/professional authorities for their acts, finance/product for offer inputs; Legal only an uncovered law/authority question | OPEN — priorities are recommendations; actual additional scope, pricing, capacity and acceptance remain unselected/unverified | |
| O-053 | D-030 settles the per-act division for CMS waiting, welcome after alignment and transfer/goodbye: approved software for clear routine updates, Philippine L1 for actual factual/logistical human help, PR L2 for relationship/distress/required navigator work. D-032 settles first introduction to the accepted assigned PR navigator during initial assessment/planning, within useful existing work and with honest pending-alignment status. Remaining facts: actual primary assignment/acceptance, working coverage/backup, person-facing handover evidence, allowed mode/contact qualification and implementation. No new enrollment/programme actor, clinical/release/signing power, mandatory duplicate welcome call, clinical gateway or continuous PR shift is inferred | Actual navigation/Ph support leadership, HR/Workforce for coverage, product for approved routing; clinical/Legal only their genuine protected question | PARTIALLY SETTLED under D-030/D-032; actual assignment/coverage/mode acceptance OPEN | |
| O-054 | Determine the clinical response actually required by the executed Agreement, applicable safety/clinical duties and chosen service offer; approve the route, hours, clinician type, actual clinical subject/current-location authority and applicable provider-location requirements, separately from caller/reporting location, response expectation, backup, concurrent demand, failed-connection disposition and funding for that exact promise. A human helpline under D-026 does not itself require a Proxi-employed clinician or Puerto Rico shift around the clock. For clinical requests when the usual team is unavailable, name the approved treating-provider, other clinical or emergency route and the permitted waiting/callback disposition; L1/L2 never decide that a caller can safely wait. Cost paid availability separately from actual clinical-event minutes and count the event once | CMO/clinical operations/finance/Participant authority | 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 genuinely shared 24/7 capacity and actual program work at sub-scale panels: surcharge, accepted cross-Participant roster sharing, minimum panel or phased launch. Declare the covered cohort, hours/language/response scope, Participant-specific multiplicity, variable/step drivers and concurrency thresholds for every cost pool. One 5,000-life PH roster plus ten distinct 500-life program blocks is mathematically coherent if those are the real contracts; one universal divisor is not required. Do not dilute unshared or variable work, unknown fees or a required second seat to zero | Finance/operations/compliance/executive | OPEN; Manual22 pool cells are scenarios, 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-062 | Approve the first-use community-service usefulness follow-up policy: which service classes require or permit follow-up; the event-based timing from first confirmed use; who may supply the result; the no-response and conflicting-report treatment; what exact evidence makes follow-up not applicable; and how the result or non-applicability returns to the Care Plan and unresolved-work record | Product/care navigation/compliance/operations | OPEN; operator preference, workload, silence, or an organization report cannot make usefulness follow-up not applicable, and no usefulness result may be inferred | |
| O-063 | Accept the GUIDE contact-window implementation from current CMS/Agreement text: calendar-month/reset treatment where documented, partial months, tier effective dates, low-dyad/RCC transitions, late/corrected BAR and overdue recovery. Keep O-047 retroactive claims and O-050 refusal separate; no invented universal rolling-day clock. | Design-time GUIDE service leadership, Billing/Revenue Cycle and Legal Counsel using actual Agreement/CMS authority | OPEN | |
| O-064 | Accept qualifying-contact evidence and covering-navigator rules: actual individual/organization/credential, participant/permission and allowed modality, substantive support purpose, interrupted/short/inbound contact, record correction and duplicate suppression. Separate public CMS minimum from Proxi useful-result/record design and O-009 monthly service/payment; no fixed-minute or all-domain checklist threshold. | Actual GUIDE care-team leadership with Billing/Revenue Cycle and Legal Counsel for controlling requirements | OPEN | |
| O-065 | Accept general supplemental SMS consent/content/identity and number rules: recipient-specific affirmative consent and authority, wrong/shared/changed number, safe content, accessible choice, withdrawal/suppression, renewal and retained evidence. O-061 separately governs Daily Companion/Caregiver View mechanics; SMS never qualifies for minimum navigator contact. | Legal Counsel and actual GUIDE service leadership with product implementation | OPEN | |
| O-066 | Name the actual company role/person and delegated signature authority for agreements Proxi itself is legally permitted to enter after D-027 business approval; scope/limits, entity, evidence, effective period, backup and execution return. Leon has been asked whether the same designated Administrative Manager also signs or a separate person signs. Do not infer signing power from business approval or grant authority for any Participant-retained agreement/signature; actual Participant party/authority remains O-PA-001 | Leon for company delegation; Legal Counsel only actual legal scope question | OPEN — direct question pending | |
| O-PA-001 | Obtain and cross-check the acquired Participant's executed GUIDE Participation Agreement and appendices before activating PA-dependent rules. Leon confirmed on 2026-10-04 that the executed Agreement and Appendix D are not available yet. Continue source-labeled public requirements, independent permitted work and draft review without claiming final Participant-specific acceptance. 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 | Controlling-document validation and actual Legal/Participant authority, not a beneficiary-case specialist | BLOCKED -- owner confirms controlling document unavailable; public semantic work continues |
Change proposal template#
Proposal ID:
Affected decision/rule/SOP:
Current position:
Proposed change:
Evidence:
Operational impact:
Clinical/compliance impact:
Cost impact:
Required approvers:
Disposition: