Status: Semantic Care Plan, Care Coordination, and Medication Management draft register; detailed medical-SOP extensions added; not operationally approved
Register schema#
| Field | Definition | Review |
|---|---|---|
| Edge-case ID | Stable pillar-prefixed identifier | |
| Trigger | Event or condition invoking evaluation | |
| Required facts | Canonical inputs required | |
| Deterministic condition | Reproducible rule expression | |
| Default state | Proceed, hold, retry, block, or escalate | |
| Automation allowed | Exact permitted automated actions | |
| First human | Lowest-cost role permitted to resolve | |
| Escalation | Next role/path if unresolved | |
| SLA | Timer attached to state | |
| Closure evidence | Objective artifact required | |
| Billability effect | Relationship to GUIDE service evidence | |
| Test cases | Positive, negative, ambiguous, and failure-path cases | |
| Applicable states | Every state from which the edge case may interrupt or be detected | |
| Fact provenance | Source, observation/receipt time, lifecycle state, and immutable event IDs | |
| Authority gate | Exact role or deterministic evidence gate permitted to resolve the case | |
| Communication behavior | What may be prepared, released, withheld, cancelled, or disclosed | |
| Retry/timeout/fail-safe | Bounded attempts, timer origin/calendar, exhaustion transition, and safe retained state | |
| Related rule versions | Stable rule IDs and versions implementing the disposition | |
| Exact assertions | Expected fact truth, transition/task/evidence, retained history, and terminal/hold outcome |
Cross-pillar seed cases#
| ID | Edge case | Default disposition | Review |
|---|---|---|---|
| X-001 | Patient identity does not match across sources | Block association; administrative verification | |
| X-002 | Caregiver authority is missing, conflicting, or revoked | Block only the affected disclosure or decision. L1 obtains missing administrative identity evidence; L2 clarifies participation, preference, permission, or relationship facts but does not decide legal authority or clinical capacity; a complete verified fact pattern that fits no approved legal rule goes only to Healthcare Legal Counsel; a clinical capacity question goes to the exact beneficiary-location-authorized clinician; a verified policy gap becomes design-time policy work, not a generic case performer. Receiving the caregiver's report and independent emergency-safe work continue. | |
| X-003 | Required information is missing | Automated retrieval, then VA pursuit, then domain owner | |
| X-004 | Canonical sources conflict | Preserve conflict; route to domain authority | |
| X-005 | Data exceeds staleness threshold | Mark stale; refresh before material action | |
| X-006 | External party does not respond | Timer-based retries and role escalation | |
| X-007 | Communication delivery fails | Approved channel fallback and receipt verification | |
| X-008 | Possible immediate safety concern | Pause only dependent routine work and invoke the approved immediate emergency, crisis, protective, or beneficiary-location-authorized U.S. clinical route. L1 and software do not determine individualized urgency. Failed connection remains an active unresolved obligation; sibling nonurgent concerns are preserved for re-entry. | |
| X-009 | AI extraction confidence is inadequate | Candidate only; deterministic verification task | |
| X-010 | No deterministic rule matches safely | Block action; human exception review; create rule-gap ticket | |
| X-011 | Concurrent updates create version conflict | Block second commit; assigned owner resolves | |
| X-012 | Patient moves, enters hospice/LTC, or dies | Eligibility/status workflow | |
| X-013 | System/EHR/network outage | Downtime queue; no silent dropping or assumed completion | |
| X-014 | Required human misses SLA | Escalate to designated backup; preserve original task | |
| X-015 | Evidence is insufficient to close | Remain open regardless of human narrative assertion | |
| X-016 | A contact, review, education event, plan edit, or other activity is scheduled solely to fill an otherwise empty billing month, or a planned contact cannot name a specific service and person-facing result | Do not furnish or claim a manufactured service. Preserve alignment, contact cadence, and actual open needs separately. For a tier-required contact, provide a genuine person-led ongoing-monitoring/support interaction with at least one attributable person-specific outcome and a usable next step/help route. For optional outreach, cancel or redesign unless staff can state the real request, event, goal/action, open promise, due work, or need; the service to be furnished; why the person's participation is needed; and the expected value. Unasked topics remain unasked and receive no no-change credit. | |
| X-017 | A naturally occurring inbound navigator interaction independently satisfies the current contact window while a duplicate outbound appointment remains | Apply the same substantive-contact review; if it qualifies, use it for the window and cancel the redundant appointment unless another distinct required or beneficiary-requested purpose remains | |
| X-018 | A beneficiary or permitted caregiver explicitly declines one required-cadence contact, requests a standing stop, or refuses a channel or topic | Distinguish a one-time reschedule, channel/topic preference, standing cadence refusal, and program withdrawal. Honor the one-time or preference case immediately. For a standing refusal, record the authenticated choice and reason, offer compliant lower-burden alternatives, continue only agreed contact, never fabricate a contact or relabel refusal as unreachability, and send the billing/alignment consequence to O-050. A separate safety signal keeps its approved route. Tests include one-time decline, standing refusal later reversed, beneficiary/caregiver disagreement, single-channel refusal, refusal with an independent safety concern, and a refusal month with no service or claim. | |
| X-019 | Continuous human access is incorrectly treated as continuous Puerto Rico or in-house clinical staffing, or a Philippine nurse's nonclinical first answer is credited as another human/clinical service | Apply D-026: the Philippine L1 nurse continuously answers and performs only approved nonclinical work. A routine factual call has zero required L2/L3/L4 contribution. Substantive caregiver support is a separate direct care-team act; verify actual membership/training/scope under O-001, not the nursing title. Protected clinical judgment uses the exact clinical-subject-location-authorized professional and approved route hours/response/backup under O-004/O-054; L1/L2 may not decide that a concern can wait. An explicit emergency uses its immediate local route. Check actual on-duty/off-duty acceptance and operational mandatory sharing before launch; a staffed unapproved interval or permanently blocked sharing route is not ready. Record first answer, actual support/clinical result, still-open callback and team sharing separately. Test a 2 a.m. service-status question with no Proxi clinician shift; caregiver support with and without approved Philippine care-team capacity; a clinical concern while the usual team is unavailable; an unapproved morning-delay decision; an explicit emergency; and an attempted automatic clinical/service credit from nursing licensure or human pickup. |
Comprehensive Assessment edge cases#
Status: DRAFT semantic cases accepted for the next assessment review. These cases implement D-018 without pretending that every missing fact blocks every lane.
| ID | Trigger and dependency | Default work disposition | Human authority, closure evidence, and minimum tests | Review |
|---|---|---|---|---|
| AS-E01 | A low-cost pre-screen finds a potentially disqualifying nonclinical eligibility fact, such as incompatible Medicare enrollment/payer status, hospice/PACE, another GUIDE alignment, an ineligible residence arrangement, or refusal of the required GUIDE relationship. | Verify the exact fact before committing the full assessment team. Pause substantial assessment preparation while the likely disqualifier is unresolved. Do not call the person CMS-ineligible from a candidate fact; CMS makes the alignment determination from the PAAF. A separate medically appropriate non-GUIDE evaluation may continue under its own authority. | Software retrieves, source-dates, and compares authoritative evidence under the approved eligibility rule; Philippine L1 pursues only a missing administrative fact. The Medicaid Program Specialist answers only an unresolved Medicaid-program question, and Healthcare Legal Counsel answers only a complete uncovered legal-authority question. Any Participant-retained eligibility disposition without an approved actual performer remains SOP DESIGN BLOCKED — NOT OPERATIONAL under O-PA-001. Close with the verified fact, source, exact authorized disposition, and independent work that continues. Test stale payer data, a recent hospice election, RCC approval missing, memory-care ambiguity, another-participant alignment, correction after the pause, and a person who still needs a non-GUIDE clinical assessment. | |
| AS-E02 | The person has suspected dementia but no prior external written diagnosis or the rostered clinician cannot yet attest to dementia. | Absence of an outside diagnosis does not block the initial comprehensive assessment: CMS uses that assessment to help confirm dementia. If the assessment shows further diagnostic testing is needed, block the PAAF/alignment, GUIDE claims, and costly post-alignment service build; continue only diagnosis-linked work, immediate safety work, and independent work that remains clinically useful and properly authorized. | The beneficiary-location-authorized U.S. dementia-proficient prescribing or Part B E/M clinician on the GUIDE Practitioner Roster performs the clinical assessment and determines whether its evidence supports attestation or a specific additional evaluation. Close with that clinician's attributable attestation based on the completed assessment or qualifying written report, or a truthful non-dementia/insufficient-evidence disposition. Test suspected dementia, MCI only, claims code without attestation, adequate assessment-based attestation, missing outside report, additional testing, and no dementia found. | |
| AS-E03 | One assessment fact or domain is missing, stale, declined, invalid, or conflicting, but other domains do not depend on it. | Continue the unaffected interview, screening, caregiver, social, provider, and administrative work. Hold the affected interpretation, final integrated synthesis, PAAF completion, and any downstream action that needs the unresolved fact. A source-linked synthesis draft may preserve completed domains and the explicit gap, but it is not the attested final assessment. Never convert missing to normal or let completed lanes imply whole-assessment completion. | Philippine L1 obtains a missing administrative source; Puerto Rico L2 clarifies only a nonclinical participation, preference, relationship, or practical fact; the exact beneficiary-location-authorized L3-RN, L3-Behavioral, or L4 clinician resolves the protected interpretation within scope. Software re-evaluates the approved completeness rule. Any Participant-retained submission disposition without an approved actual performer remains blocked under O-PA-001. Close with replacement evidence or an explicitly permitted disposition, the affected dependency, and the independent cards that continued. Test missing medication source, invalid stage, declined advance-planning question, caregiver/beneficiary conflict, late correction, and unrelated HRSN work continuing. | |
| AS-E04 | A clinical assessment component or outside result is pending and a nonclinical lane may or may not depend on its outcome. | Use the stated dependency, not the word “clinical,” to decide. Continue low-cost scheduling, accessibility preparation, source gathering, and independent nonclinical domains. Pause any recommendation, risk conclusion, care-plan element, instruction, or service selection whose meaning could change with the result. | The exact beneficiary-location-authorized L3-RN, L3-Behavioral, or L4 clinician responsible for the pending question identifies which conclusions and actions depend on its result; an external professional supplies only its own source-native result. L2 continues only independently useful nonclinical work. Close with the returned result, qualified interpretation, and documented list of work released, revised, or still held. Test pending hearing evaluation, pending medication reconciliation, pending capacity/authority question, unrelated caregiver assessment, late abnormal result, and work completed before a contradictory result arrived. | |
| AS-E05 | An urgent clinical, behavioral-health, abuse/neglect, or immediate safety concern appears during otherwise routine assessment work. | Stop the affected routine questioning and invoke the approved live pathway. Preserve every already collected fact and keep unrelated lower-priority needs queued rather than dropping them. Resume only when the receiving authority says the routine interaction can safely continue. | Philippine L1 may capture identity, current location, and callback information and perform a protocol-driven warm transfer; Puerto Rico L2 may provide nonclinical relationship support but neither determines urgency. The exact beneficiary-location-authorized L3-RN performs an in-scope nursing/symptom/safety assessment, the L3-Behavioral clinician performs an in-scope behavioral/suicide/safeguarding assessment, the L4 clinician performs the required higher medical act, or the named emergency, protective-service, or law-enforcement endpoint performs its own response. Closure requires matched acceptance and authoritative disposition, not merely a transfer attempt. Test suicidality, sudden confusion, current abuse disclosure, caregiver danger, failed handoff, false alarm, and later resumption of unfinished domains. | |
| AS-E06 | An eligibility criterion is confirmed false before or after assessment work begins. | Stop the GUIDE alignment path and avoid further GUIDE-only investment. Preserve valid clinical evidence, communicate truthfully, and route any medically appropriate ordinary-care service under its own coverage and authority. Do not submit a PAAF as eligible or promise alignment. | Software applies only the approved rule to authoritative administrative facts; Philippine L1 obtains a missing source; the Medicaid Program Specialist answers only a Medicaid-program question; the beneficiary-location-authorized L4 dementia-proficient clinician owns the dementia assessment and attestation; CMS supplies the final alignment result. Any separate Participant-retained exclusion or submission act remains blocked under O-PA-001 until its actual performer is approved. Close with the confirmed source fact, exact authorized disposition, person communication, preserved clinical evidence, and non-GUIDE disposition. Test MCI/no dementia, MA/PACE/hospice, another GUIDE alignment, Memory Care Unit, unapproved RCC, final CMS ineligible result, and a later correction. | |
| AS-E07 | CMS returns a real-time preliminary alignment result, pending review, or a final BAR result that differs from internal expectations. | Preliminary status may support CMS-permitted internal care planning only. Except for the specified pre-alignment assessment/alignment work, do not furnish or bill ongoing GUIDE services until the final Beneficiary Alignment Report confirms alignment. Hold mismatched or absent final results for exact administrative reconciliation. | Software retrieves and matches the exact PAAF acknowledgement, preliminary response, and final BAR to the beneficiary and submission. Philippine L1 pursues a missing or mismatched CMS administrative artifact; the actual L3/L4 author corrects only its own clinical source fact; Billing and Revenue Cycle handles only an actual claim consequence; System Administration or Software Engineering enters only for a confirmed integration or product failure. Any Participant-retained activation or non-alignment act without an approved performer remains blocked under O-PA-001. Close with the matched final BAR, tier/effective date, exact activation or non-alignment disposition, and person notice when applicable. Test preliminary aligned then final ineligible, no final result, wrong patient, corrected PAAF, tier change, and attempted pre-final service claim. | |
| AS-E08 | Caregiver status is unknown, a caregiver exists but required caregiver data is missing, or no caregiver is confirmed after reasonable effort. | Unknown status remains open. A confirmed absence of a caregiver is not an eligibility failure: continue the beneficiary assessment and no-caregiver safeguard branch, while caregiver-assessment and caregiver-support sections become inapplicable. If a caregiver exists but required burden data is missing, hold the affected PAAF input while unrelated domains continue. | Puerto Rico L2 performs the relationship-based caregiver-status clarification and reasonable identification effort; each caregiver supplies only their own information; software applies the approved PAAF completeness rule without inventing an answer. An unresolved legal-authority question goes only to Healthcare Legal Counsel, and any Participant-retained submission/completeness act without an approved performer remains blocked under O-PA-001. Close with identified caregiver data, confirmed no-caregiver safeguards, or a truthful unresolved item and the independent domains that continued. Test no caregiver, unreachable possible caregiver, multiple caregivers, declined burden assessment, late caregiver identification, and unrelated domains continuing. | |
| AS-E09 | A required/elected in-person residence visit has only remote staff, an unapproved or unqualified contractor, an unsuitable telehealth procedure, failed connection, unavailable onsite worker, or missing/unsafe observation. | Under D-028, use the paid outsourced social worker/home-safety specialist physically onsite as an approved care-team/Partner member, paired with one appropriately scoped Proxi telehealth clinician for the actual clinical assessment. Remote PR participation, a booking or a video connection does not substitute for onsite presence or the clinical result. Hold only the affected visit/domain; independent permitted assessment work continues. Preserve the RFA two-calendar-month visit expectation separately from PMP's 60-day staging-to-completion/PAAF deadline; apply current low-tier mode/PAAF requirements without inventing an onsite fee. | Software checks facts/credentials, schedules the joint encounter, prepares observation and clinical packets and tracks the real deadline. Philippine L1 pursues only missing objective logistics; the approved contracted worker performs onsite observations, and the selected U.S. clinician performs the actual protected act within scope/subject-location/modality authority. An unavailable worker uses an approved qualified backup, not an invented role or unbounded retry; actual availability/retry promises and fee/travel remain O-039/O-PA-001. An immediate hazard uses X-008. Close with actual physical presence, approved worker/clinical identities and authority, direct/reported/unobserved findings, clinical result, limitations, safeguards and next work. Count shared visit/clinical minutes once, paid field fee separately. Test required visit with remote PR only; low-tier permitted remote visit; approved versus unapproved contractor; missed visit; changed residence; connection failure; clinically inadequate remote observation; unsafe demonstration refused; late deadline; observation copied as a clinical conclusion; and duplicate clinician billing. | |
| AS-E10 | A caregiver and beneficiary are in different jurisdictions, or a caregiver's own health/distress question is incorrectly routed using the beneficiary's location. | Identify the actual clinical subject and exact licensed act before routing. Use beneficiary-location authority for beneficiary care even when reported by the caregiver; use caregiver-location authority for the caregiver's own licensed care, plus applicable provider-location rules. Nonclinical coaching, stated preferences and structured strain capture do not automatically become licensed clinical care. An unresolved protected assignment holds only that act while safe independent support continues. | Software preserves subject, reporter, current location/date and exact question; L1/L2 collects only permitted missing facts; the actual scoped U.S. professional performs the clinical act. No extra generic reviewer. Close with the subject/location/authority, actual clinical result and return recipient when a licensed act occurs, or the attributed nonclinical result when none is needed. Test caregiver reporting a beneficiary medication concern from another state; caregiver's own severe distress in a different state; location unknown/changed; provider-location restriction; routine education without a clinical act; and an immediate emergency requiring local help. Supports SRC-HHS-TELEHEALTH-LICENSURE and SRC-HHS-TELEBEHAVIORAL-LICENSURE. |
Ongoing Monitoring and Support edge cases#
| ID | Trigger/condition | Required handling and detecting tests | Review |
|---|---|---|---|
| OM-E01 | A passive Proxi signal, AI conversation, SMS, reminder, L1 call, failed attempt or infrastructure is proposed as navigator contact or monthly service. | Keep the attributed input/admin event; no cadence/service/payment credit. Actual human L2 purpose/modality/content and source-faithful record use O-064; monthly service uses O-009 separately. Test short substantive L2 work, long scheduling-only call, AI-only interaction and an off-contact low-dyad/RCC month with an actual independent service. | |
| OM-E02 | Beneficiary report, caregiver pulse, external source and last baseline disagree, are stale or silent. | Preserve speaker/subject/time and unknowns, not a model-selected winner or reassurance. Bring a relevant question to a due/justified interaction or exact protected route; a requested human response remains open until its actual return. Test different-day reports, same-event disagreement, caregiver-own exhaustion, stale medication record and no response. | |
| OM-E03 | Contact fails repeatedly, but no independent current danger fact exists; or a late authenticated refusal arrives. | Approved deterministic reach endpoint may need zero people. L1 corrects actual route/access facts; L2 enters only for a named relationship/burden/refusal/participation act; no default clinical/welfare review from silence. O-055 controls attempts, O-050 refusal, O-013 no-caregiver safeguards. Test wrong number, interpreter failure, no known risk, refusal after attempts and independent immediate danger before the attempt threshold. | |
| OM-E04 | Caller, beneficiary and caregiver are in different locations, or the question needs prescribing, nursing, behavioral or pharmacy authority. | Identify actual care recipient/location and exact act, plus applicable provider-location rules. No L2/RN gateway. Reuse directly applicable current scoped professional instructions without new work; a new protected observation, symptom, discrepancy or instruction needs the exact professional. Test beneficiary symptoms reported remotely, caregiver-own licensed care, both subjects, medicine product-method versus regimen change and stale/conflicting instruction. | |
| OM-E05 | A prepared referral/clinical/medication packet is ready, but actual V1 human-release execution is missing. | Internal preparation/independent care may continue; hold the unsupported external transmission. D-007 ordinary community referral needs its actual L2 or approved lead backup 1–2-minute release; other classes retain O-014/O-021/O-030/Agreement dependencies. Reuse one actual release evidence/time record, never infer release from clinical authorship or permission checks. Test changed destination, missing performer, approved backup and same-contact release counted once. | |
| OM-E06 | One inbound conversation fulfills several distinct services or opens several promises; direct emergency acceptance occurs without a Proxi clinician. | Credit only actual separately evidenced service content/results; opening work is not furnishing it. Count L1 first answer once with Access, one L2 contact once and each actual receiving professional once. Clear digital administrative response can use zero people; direct external emergency response need not purchase L2/RN first. Retain continuing clinical/other obligations and funded availability separately. Test digital appointment fact, L1→L2→one clinician, same-call CG26 support, shared office pursuit, pending versus returned promises and direct911 acceptance with no Proxi clinical act. | |
| OM-E07 | Workload output omits aligned people, has stale tier/credential facts, or implies a routine manager review on an evidence-complete no-gap result. | Use the complete current aligned denominator and approved O-063/O-064 bases. Missing facts are unknown, not no-gap. L1 obtains an actual objective report; PR lead repairs assignment, HR repairs workforce and technical jobs repair their real fault. Complete verified no-gap needs no routine attestor; actual gaps remain until repaired or truthfully held. Portfolio work creates no beneficiary service credit. Test missing person, stale BAR, expired credential, no-gap, repaired gap with unusable appointment and clinically authorized extra frequency reused without new clinical review. |
Caregiver Education and Support edge cases#
These cases govern the actual work in Manual 16 without adding a runtime model. O-036/O-PA-001 retain provider/completion acceptance; actual response, retry and coverage promises remain their approved source rules.
| ID | Trigger and required facts | Work and authority | Evidence and tests | Review |
|---|---|---|---|---|
| CG-E01 | Skills trainer/group provider is wrongly treated as free outside/Participant work; need service, actual provider, team/Partner status, contract/reimbursement, time/fee and free-community basis. | Proxi staff and contracted GUIDE delivery are paid under D-012. Only a verified community support group offered free under §8.3.3 uses the free-group route; it is not a skills-training vendor exception. Unapproved provider/arrangement holds only that delivery. Software seeks approved alternatives; existing lead/HR repairs capacity and Administrative Manager only approves a new business commitment. | Actual accepted provider/arrangement, delivery and correct paid/free classification; no fee invented at PR rate. Test paid trainer, paid community class, same organization's free support group, missing/expired arrangement, hidden fee and alternate provider. | |
| CG-E02 | Topic delivery, D-019 application, later usefulness or monthly qualification is promoted into another result; need actual content/provider/participation, human response/correction, later report and applicable service prerequisites. | Preserve all four separately. No AI-only current-route completion, compulsory quiz, RN co-signature or fabricated success. Partial/declined/non-success outcomes retain actual delivered care; they do not themselves permit a claim. Whole-event acceptance remains O-036. | Separate delivery/application/follow-through/qualification records with unknowns. Test video only; permitted delivery with application declined; one topic missing; later helped without delivery; delivered but not tried; patient refuses; service evidence exists while claim prerequisite is missing. | |
| CG-E03 | Live show-me is requested without safe voluntary scope/instruction, or a clock estimate is used as stop/fail/referral; need skill, safe setting/method, consent/assent, current instruction, trainer scope and access needs. | Accessible plan-back is ordinary; voluntary in-scope observation may use simulation. Do not force a patient transfer, swallowing/medicine act or bathing to prove learning. Actual protected technique goes to its exact professional; a declined live demo gets a safe alternative. The 5/10/20 estimate does not complete/fail/truncate care or cause clinical referral. | Actual response, alternative/correction, remaining need and real paid time. Test usable in 3 minutes,14-minute correction,30-minute interpreter encounter, pause at 7, safe simulation, declined live transfer, unsafe swallowing demonstration, patient refusal and focused second session. | |
| CG-E04 | Group session cost is multiplied by attendees, or one learner's evidence is assigned to all; need actual facilitator/qualification, session/fee, preparation/documentation, actual attendees and participant-level evidence. | Count each actual paid person's session once; allocate transparently for costing only. A 60-minute facilitator with 8 actual attendees is 60 total/7.5 per attendee before additional real prep/documentation, not 480. Quiet listening is permitted group participation; no compelled personal disclosure. Support-group evidence is distinct from individual skills application. | One real session/time/fee record, attendee evidence and separate learning results. Test 8/6 actual attendees, late join, quiet participant, absent facilitator, paid versus free group, simulated group application, private clinical disclosure and flat fee plus duplicate hourly charge. | |
| CG-E05 | Clinical question is routed by caller/title/topic instead of actual act/subject, or unapproved Philippine nurse is treated as trainer/support/clinician; need exact report, current instruction/unknowns, subject/current location, proposed act and accepted professional scope. | Apply AS-E10: beneficiary care uses beneficiary location; caregiver's own licensed care uses caregiver location; dual acts are separate and provider-location rules apply. General physical/personalized teaching is not automatically clinical. Reuse a current product unless a new protected act is needed. L1 prepares/connects; O-001 must approve any exact nonclinical care-team act, never U.S. clinical authority from Philippine title. Immediate safe local response is not delayed for routine teaching or a perfect packet. | Actual scoped receiver/acceptance/result and permitted return, with failed handoff still open. Test general bathing plan, new transfer pain, medication method, stale therapy instruction, NY caregiver own distress versus FL beneficiary concern, unknown/changed location, two subjects, unapproved L1 teaching and approved member with out-of-scope clinical question. | |
| CG-E06 | Later intended-use result is absent, corrected, not tried, unhelpful or unsafe, or a new call is manufactured solely for it; need original intended action, actual natural opportunity, caregiver's report and next need. | Ask only at the next natural contact/CG26/permitted asynchronous exchange. Preserve report/correction without rewriting original delivery. Nonuse/patient refusal does not prove incapacity; unhelpful result gets targeted safe reinforcement, and unsafe/current concern opens CG27. No quality-only/billing-filler call or retrospective service credit. | Caregiver-owned result/unknown/correction and exact next action. Test helped/partly/not-helped/not-tried, no natural contact yet, corrected prior answer, privacy restriction, patient refusal, unsafe attempt and duplicate outbound appointment. |
Care Plan edge cases#
Status: DRAFT v0.2. Existing rule references identify the rule family; their v0.2 semantics and any new rule IDs must be assigned and tested during the Care Plan machine migration. Numerical SLAs remain provisional under O-004 unless a CMS deadline is stated.
| ID | Trigger, required facts, and provenance | Deterministic gate and default state | Permitted automation and first human | Clock, communication, fail-safe, closure evidence, and minimum tests | Review |
|---|---|---|---|---|---|
| CP-E01 | A required content-manifest item is absent. Requires case/version, item applicability, source attempts, authority, and immutable retrieval events. | CP-002/CP-003 family; hold MISSING_INFORMATION. Unavailability is not an exception unless an authorized exception class exists under settled O-015. | L0 retrieves; L1 pursues administrative records; L2/domain owner resolves household or substantive facts. | Bounded attempts and backup escalation; do not publish affected element. Close with obtained fact or a pre-existing authorized exception after O-015 is settled. Test each required item, unavailable source, exhaustion, and late arrival. Care Plan service qualification remains separate under O-017. | |
| CP-E02 | A material dependency is explicitly stale or expires before action. Requires value and record_state, expiry rule/version, source, and affected elements. | CP-023/CP-003 family; enter MISSING_INFORMATION and block the affected element. Stale/missing cannot satisfy neq/not_in. | L0 marks and requests refresh; fact owner resolves. | Timer begins at stale detection; preserve prior active version and withhold affected communication. Close with current replacement or a pre-existing authorized exception class after O-015 is settled. Test stale on entry, after compilation, and at release. | |
| CP-E03 | An AI inference, copied preference or proposed conversational interpretation lacks exact authorized-person confirmation. Requires original statement/source, speaker identity, decision scope, exact option/plan content and material conditions, current authority, accessible route and attributable response. | CP-006/CP-010; keep the affected choice unresolved until the approved confirmation requirements are met. A clear direct response may establish the person's choice; it does not itself approve clinical content, disclosure or whole-plan completion. | Software presents the precise item and records the beneficiary/authorized representative's direct confirmation, correction, decline, deferral or question. L2 enters only for an actual D-021 human-service/support trigger. Caregiver input remains separate from beneficiary control. The exact clinician handles clinical meaning/capacity; counsel handles only a complete uncovered legal question. | No inference from silence, a portal identity alone or AI confidence. O-041 governs modes/comprehension evidence. Close only the choice-confirmation substep on the attributable response and valid authority; preserve unknowns/conditions and all independent clinical, release and contact duties. Test approved clear direct capture with zero L2 verification; AI-misstated choice corrected by the person; requested help; inaccessible route; expired representative; conditional choice; clinical alternative requested; conflicting later statement; duplicate; and no response. | |
| CP-E04 | Beneficiary and caregiver preferences differ. Requires authenticated statements, capable-beneficiary/decision status, caregiver participation, disclosure permission basis, and representative-authority facts. | CP-011 family; block only affected element. A capable beneficiary controls only when the approved decision-specific authority rules establish that result. | L0 preserves both and routes; L2 authenticates/records choices, preserves dissent, presents approved options, and routes the deterministic outcome; L2 does not decide capacity, legal authority, or whose choice controls. | Preserve dissent in all outputs permitted to receive it. Close with beneficiary decision or decision-specific authority resolution under settled O-011. Test capable beneficiary, authority unknown, and caregiver dissent without an inferred veto. | |
| CP-E05 | Multiple caregivers or representatives disagree. Requires identity, documentary basis, scope, effective/expiry dates, conditions, and decision applicability for each. | CP-011/CP-012 family; AUTHORITY_UNCLEAR; no majority vote. Controlled by O-011. | L0 assembles registry; L2 verifies; compliance/legal/clinical authority resolves as policy requires. | Withhold affected disclosure/decision; unaffected beneficiary-led elements may proceed. Close with documented controlling authority/scope and preserved dissent. Test partial, expired, conditional, conflicting, and multiple representatives. | |
| CP-E06 | Decision-specific capacity or representative authority is questioned. Requires exact decision/element, clinical evidence source, representative record, and timing. | CP-011/CP-012 family; AUTHORITY_UNCLEAR; no global capacity inference. | L0 blocks affected action; L2 verifies documents; appropriately qualified L3/L4 performs approved capacity function. | P0 signals preempt. Close with decision-specific capacity/authority evidence and expiry/review date. Test fluctuating capacity, unsupported assertion, expired document, and later restoration. | |
| CP-E07 | Caregiver status is unknown, search is in progress, or no caregiver is confirmed. Requires identification-attempt events and beneficiary authority/capability. | New v0.2 rule family; unknown remains pursuit hold; confirmed absence follows no-caregiver branch without inventing a proxy. Safeguards controlled by O-013. | L0/L1 conduct permitted search; L2 confirms status and opens only approved safeguards. | Do not deadlock a capable beneficiary. Close with caregiver status plus an approved active safeguard/contact plan, or an authorized exception defined after O-013 is settled. Test unknown, confirmed absent, later identified, unreachable support, capable beneficiary, emerging risk. | |
| CP-E08 | A clinical or medication element changed or a prior approval became invalid. Requires exact element/version/content identity, authority class, prior/current evidence, and actual approver. | CP-013 family; CLINICAL_REVIEW_REQUIRED unless manifest derives NO_CLINICAL_AUTHORITY_REQUIRED. Routing controlled by O-003. | L0 compiles/routes; L3, L4, or L5 acts only within actual scope. | Withhold only affected instruction; no universal RN approval. Close with approver identity/credentials/scope and exact element/version evidence. Test preference-only, RN, prescriber, external, mixed, and invalidated approval. | |
| CP-E09 | PCP and specialist recommendations conflict. Requires verbatim recommendations, provenance, dates, affected elements, and provider identities. | Proposed CP-055 v1.0.0; CONFLICTED_FACTS or CLINICAL_REVIEW_REQUIRED; preserve both. | L0 detects structured conflict; L1 may request already-existing documentation and record verbatim administrative outcomes but must stop on dispute, interpretation, or new instruction; L3/L4/L5 resolves within authority. | No administrative relay as resolved instruction. Close with authorized course, rationale, and source notifications as required. Test partial conflict, no response, superseded recommendation, and P0 content. | |
| CP-E10 | Beneficiary refuses a recommendation. Requires authenticated refusal, decision-specific capacity/authority, explanation source, offered authorized alternatives, and affected element. | New/versioned beneficiary-validation rule; preserve refusal; never convert refusal to missing consent or caregiver veto. | L2 authenticates preference; L3/L4 explains clinical consequences/alternatives when needed. | Communicate only approved content; P0 remains separate. Close with informed-refusal evidence and revised/unchanged plan disposition. Test capable refusal, representative conflict, partial refusal, and later change. | |
| CP-E11 | Possible immediate safety concern from any nonterminal state, or a new signal after terminal closure. Requires signal source/time, current/prior case state, subject, and handoff events. | From a nonterminal state, the cross-state rule linked to X-008 preempts to SAFETY_ESCALATED and opens a separate safety case. After terminal closure, it opens a separate safety case and, if plan-relevant, a new linked care-plan case; the old case never transitions. | L0 stops affected routine actions and summons immediate US pathway; L1 must stop; L3/L4/emergency path acts. | Immediate, including after hours; retry failed handoff without assuming success. Safety handoff is not care-plan closure. Test every nonterminal state, post-terminal signal, duplicate signal, false positive, failed handoff, and resume/new-case disposition. | |
| CP-E12 | Concurrent edit, duplicate/mismatched EHR acknowledgement, or version/content conflict. Requires case/version/content identity, duplicate-prevention key, submission, acknowledgements, and prior active version. | CP-014 family rewritten as submission/acknowledgement rules; VERSION_CONFLICT; prior plan stays active. Policy controlled by O-016. | L0 submits without duplication and reconciles the exact acknowledgement; plan owner/clinical informatics resolves. | No activation or distribution of a mismatched version. Close with one exact incorporated version and conflict disposition. Test wrong content/version, duplicate acknowledgement, two editors, delayed stale acknowledgement, and retry exhaustion. | |
| CP-E13 | A required recipient obligation fails at release, transmission, delivery, or access. Requires version-bound obligation denominator, controlling permission basis, recipient, exact approved content identity, channel, attempts, and outcomes. | CP-019/CP-020 family; DELIVERY_FAILED; activation remains distinct. Satisfaction/exception controlled by O-012. | L0 prepares/records; authorized human releases; L1 verifies the endpoint and may prepare a re-send, but execution is blocked until O-001/O-014 are settled and the exact release event permits it; L2/privacy handles refusal/permission ambiguity. | Bounded channel-specific retry; re-evaluate on revocation/supersession. Successful ACTIVE requires satisfaction or a pre-existing authorized exception after O-012 is settled. Failure/exhaustion alone remains open in DELIVERY_FAILED. Test wrong endpoint, portal without access, fax without ack, refusal, and no caregiver. | |
| CP-E14 | A caregiver/recipient permission basis is revoked or narrowed before/after release. Requires basis type, recipient, purpose/scope, effective time, queued/sent packets, access controls, any independent basis, and affected representative-derived choices. | New privacy-revocation rule linked to X-002; cancel/disable only actions dependent on the revoked basis, re-evaluate independent treatment/other bases, rebuild obligations, and re-evaluate affected choices. | L0 cancels controllable dependent work; L2 verifies facts; privacy/compliance resolves the legal/contractual basis, exposure, or ambiguity. | No claim of recalling sent data. Close with permission-basis decision, cancellation/access evidence, rebuilt matrix, and exposure record. Test before approval, between approval/send, after send, partial scope, independent treatment basis, and superseded payload. | |
| CP-E15 | Move, hospice, LTC, disenrollment, or death signal. Requires identity-matched status source, effective date, plan/service state, and conflicting evidence. | New status rule linked to X-012; STATUS_TRANSITION_HOLD; invoke eligibility/status workflow rather than ordinary plan closure. | L0 assembles/blocks; operations/L2/clinician resolves as applicable. | Stop inappropriate outreach/release; P0 still preempts. Close with transfer/disenrollment/final-record evidence. Test false match, conflicting dates, pending hospice, death, and late correction. | |
| CP-E16 | Annual comprehensive-assessment window is approaching, started late, or submission deadline is at risk/missed. Requires prior qualifying date, annual start, submission/ack, and interim-assessment history. | New annual-clock rule using SRC-CMS-GUIDE-PMP-3.0; start days 306-425; submit earlier of start+60 days or day 425; interim does not satisfy. Calendar-day counting is a provisional implementation interpretation pending confirmation. | L0 calculates/alerts; L2/assessment owner acts; compliance handles missed CMS deadline. | No fabricated timely status. A miss remains a compliance exception until documented disposition and corrective action; violation documentation alone is not remediation. Close with actual submission acknowledgement, linked plan event, and compliance disposition/corrective-action evidence. Test days 305/306/425/426, 60-day cap, interim, no-delta. | |
| CP-E17 | No safe rule matches or multiple ordinary action transitions are enabled. Requires state, all evaluated rule versions/truths, fact snapshot/event IDs, and engine version. | New rule-gap control linked to X-010; RULE_GAP_HOLD; no AI improvisation and no dropped concurrent blockers. | L0 freezes affected action and opens rule-gap ticket; designated domain owner/compliance reviews. | Clock under O-004; safe communications only. Close only through a new versioned rule/test or a pre-existing versioned exception class with a structured allowed human outcome and linked successor case; an ad hoc note cannot resume or close. Test every state/value and pairwise blocker overlaps. | |
| CP-E18 | EHR/system/network outage or missing incorporation acknowledgement. Requires submission/duplicate-prevention identity, exact version/content identity, outage source, attempts, and prior active version. | New incorporation-failure rule linked to X-013; remain safely pending or enter an explicit commit-failure/downtime hold; prior plan remains active. Policy controlled by O-016. | L0 queues/retries boundedly; clinical informatics/operations resolves. | No silent drop or assumed completion; withhold new-version release. Close with a matched acknowledgement or the exact rollback/alternate-workflow evidence defined after O-016 is settled. Test outage before/after submission, timeout, recovery, duplicate submission, and exhaustion. | |
| CP-E19 | Required human task misses its SLA. Requires task/rule/edge IDs, owner/backup, clock/calendar, attempts, handoffs, work/wait time, and current facts. | New miss rule linked to X-014; preserve original task and escalate to designated backup. SLA values controlled by O-004. | L0 detects/escalates; backup role acts within authority. | Notify only according to approved policy; no completion by reassignment alone. Close with substantive task outcome and miss evidence. Test holiday calendar, absent backup, repeated miss, and P0 escalation. | |
| CP-E20 | Required closure or service-gate evidence is absent, mismatched, stale, or belongs to another version. Requires closure manifest, SERVICE_GATE_RESULT, rule version, producer/actor, organization, timestamps, and exact artifact/version identities. | Proposed CP-084 v1.0.0 closure gate linked to X-015; remain open. Human narrative is not evidence substitution. Case closure and service qualification remain independent. | L0 identifies missing/mismatched items; evidence owner resolves; compliance/billing controls O-017 service-gate policy. | No terminal transition or implied billability. Close only when the exact closure manifest and explicit QUALIFYING, NONQUALIFYING, or NOT_EVALUATED_BLOCKED service-gate record pass their separate rules. Test missing actor, wrong version/content, stale approval, incomplete distribution, qualifying service, nonqualifying automation, and blocked evaluation. | |
| CP-E21 | Duplicate or late trigger arrives after a terminal care-plan case. Requires old/new event IDs, exact source/content identities, observed/received times, materiality inputs, and prior case/version link. | CP-021/CP-022 families rewritten at intake. Exact duplicate attaches provenance only; genuine material event opens a new linked case; old case stays terminal. | L0 deduplicates and links; L2/domain owner handles unresolved materiality under O-010. | No duplicate entry actions or old-case mutation. Close intake with duplicate evidence or distinct successor case ID/link. Test late older fact, exact duplicate, corrected fact, new material event, and erroneous reopen attempt. |
Care Plan execution-instantiation matrix#
For each CP-E##, the four mandatory stable test IDs are CP-T-E##-POS, CP-T-E##-NEG, CP-T-E##-AMB, and CP-T-E##-FAIL. Boundary or state-matrix tests add a descriptive suffix and link back to the same edge ID. BLOCKED(O-xxx) means no production timer, retry ceiling, exception, or closure transition may be activated until that decision is settled; it is not permission to omit the field. Every task also carries the full task packet defined in 03_SOP_Care_Plan.md section 13.
| ID | Exact applicable state(s) | Draft rule version(s) | Clock/retry/backup status | Communication and fail-safe | Review |
|---|---|---|---|---|---|
| CP-E01 | TRIGGERED, INPUTS_COLLECTED, MISSING_INFORMATION | CP-002/003 v2.0.0 | Timer/retry BLOCKED(O-004); L1 backup L2/domain owner | Prepare request only; withhold affected element; prior version remains active | |
| CP-E02 | Every nonterminal state before the affected action/release | CP-023/003 v2.0.0 | Expiry triggers immediate block; refresh SLA BLOCKED(O-004) | Mark stale and withhold affected element/packet; no negative-guard permission | |
| CP-E03 | Exact proposed choice awaiting confirmation; legacy states PLAN_COMPILED/BENEFICIARY_VALIDATION_REQUIRED remain non-activatable | CP-006 current business meaning under D-021; CP-010 | O-041 route/evidence; O-004 response policy; L2 only on its actual human-entry trigger | Person supplies an attributable authorized choice directly where approved; candidate/silence cannot settle it, and choice confirmation grants no clinical, disclosure or whole-plan authority | |
| CP-E04 | PLAN_COMPILED, BENEFICIARY_VALIDATION_REQUIRED, AUTHORITY_UNCLEAR | CP-009 v2.0.0, CP-011 v3.0.0, proposed CP-027 v1.0.0 | Timer/backup BLOCKED(O-004/O-011) | Preserve both statements/dissent; communicate only approved neutral options; block affected element | |
| CP-E05 | BENEFICIARY_VALIDATION_REQUIRED, AUTHORITY_UNCLEAR | CP-011 v3.0.0, CP-012 v2.0.0 | BLOCKED(O-004/O-011); compliance/legal/clinical backup by approved matrix | No majority vote or affected disclosure/decision | |
| CP-E06 | BENEFICIARY_VALIDATION_REQUIRED, AUTHORITY_UNCLEAR | CP-011 v3.0.0, CP-012 v2.0.0 | BLOCKED(O-004/O-011); qualified clinician required for approved capacity function | No capacity conclusion by L0/L1/L2; block affected choice only | |
| CP-E07 | TRIGGERED, INPUTS_COLLECTED, PLAN_COMPILED, NO_CAREGIVER_SAFEGUARD_REQUIRED | proposed CP-025/026 v1.0.0 | Search/safeguard timer BLOCKED(O-004/O-013); L2 owner | Do not invent proxy; continue capable-beneficiary path; only approved safeguards | |
| CP-E08 | BENEFICIARY_VALIDATED, CLINICAL_REVIEW_REQUIRED, CLINICAL_ELEMENTS_APPROVED | CP-013 v2.0.0, proposed CP-028-032 v1.0.0 | BLOCKED(O-003/O-004); L3/L4/L5 by element | Withhold affected instruction; retain unaffected content; no universal RN evidence | |
| CP-E09 | CONFLICTED_FACTS, CLINICAL_REVIEW_REQUIRED | proposed CP-055 v1.0.0 | BLOCKED(O-003/O-004); L3/L4/L5 | L1 requests existing documents only; no interpreted relay or resolved instruction | |
| CP-E10 | BENEFICIARY_VALIDATION_REQUIRED, BENEFICIARY_VALIDATED, CLINICAL_REVIEW_REQUIRED | CP-010 v2.0.0 plus authority rule | BLOCKED(O-004/O-011) | Preserve refusal; only clinician explains clinical consequences/alternatives | |
| CP-E11 | Every nonterminal state; post-terminal event opens separate/new linked case | proposed CP-046/047 v1.0.0 | Provisional IMMEDIATE_P0, BLOCKED(O-004) for activation; retry failed handoff; US human/emergency backup | Stop affected routine communication; safety case closure is separate | |
| CP-E12 | EHR_COMMIT_READY, EHR_COMMIT_SUBMITTED, VERSION_CONFLICT | CP-014 v2.0.0, proposed CP-033-038 v1.0.0 | Retry/timeout BLOCKED(O-016); clinical informatics backup | No new-version activation or release; prior version remains active | |
| CP-E13 | PLAN_ACTIVATED, DISTRIBUTION_MANIFEST_READY, ACTIVE_WITH_DISTRIBUTION_OPEN, DELIVERY_FAILED | CP-019 v3.0.0, CP-020 v2.0.0, proposed CP-039-042 v1.0.0 | BLOCKED(O-001/O-004/O-012/O-014/O-PA-001) | Human release required; L1 may prepare only; never infer receipt/satisfaction | |
| CP-E14 | DISTRIBUTION_MANIFEST_READY, ACTIVE_WITH_DISTRIBUTION_OPEN, DELIVERY_FAILED, DISTRIBUTION_REPLAN_REQUIRED; post-terminal event opens new linked case | proposed CP-043/044 v1.0.0 | BLOCKED(O-004/O-011/O-014); privacy/compliance backup | Cancel only revoked-basis-dependent work; re-evaluate independent bases; no false recall | |
| CP-E15 | Every nonterminal state; post-terminal signal uses separate status/new linked case | proposed CP-048/049 v1.0.0 | BLOCKED(O-004); operations/clinical backup | Stop inappropriate outreach/release; Care Plan does not decide eligibility/unalignment | |
| CP-E16 | Annual-obligation intake and TRIGGERED; may terminate REVIEWED_NO_CHANGE or continue new-version path | proposed CP-045, CP-050-054 v1.0.0 | CMS day-306/day-425/earlier-of-60 clock; date convention/timezone BLOCKED(O-018); compliance backup | Never mark a miss timely; reassessment does not satisfy annual; late work continues | |
| CP-E17 | Every nonterminal state | proposed CP-090/091 v1.0.0 | Review timer BLOCKED(O-004); domain owner/compliance | Safe status only; no ordinary action, ad hoc exception, or LLM improvisation | |
| CP-E18 | EHR_COMMIT_READY, EHR_COMMIT_SUBMITTED, EHR_COMMIT_FAILED, EHR_DOWNTIME | proposed CP-035-037 v1.0.0 | Retry/timeout BLOCKED(O-016); clinical informatics/operations | Queue durably; no silent drop, assumed ack, activation, or release | |
| CP-E19 | Every nonterminal state with a human task | proposed CP-080/081 v1.0.0 | Numeric SLA BLOCKED(O-004); preserve original task and named backup | Escalation notice only; reassignment is not completion | |
| CP-E20 | Every source state attempting ACTIVE, REVIEWED_NO_CHANGE, DUPLICATE_EVENT_RECORDED, or TRIGGER_REJECTED | proposed CP-084 v1.0.0 closure gate and CP-082/083 v1.0.0 service gate | Closure remains blocked by every applicable OPEN/BLOCKED decision | No terminal or billing inference; explicit closure manifest plus separate service-gate result | |
| CP-E21 | New TRIGGERED intake linked to a prior terminal case | CP-021/022 v2.0.0 | Materiality review BLOCKED(O-004/O-010); L2/domain owner | Duplicate adds provenance only; genuine change creates successor; never mutate old case |
Care Coordination edge cases#
Status: DRAFT semantic register. Existing IDs CC-E01 through CC-E20 retain their original subjects; their closure language is corrected below so that resolving an attempt or child obligation never silently closes the parent case. New rule IDs and machine states are deliberately deferred until the semantic SOP set and later fault gates are complete. Numeric operating clocks remain blocked by O-004 unless a current CMS deadline is named.
| ID | Trigger, required facts, and provenance | Business gate, permitted automation, and human authority | Communication, fail-safe, objective outcome, and minimum semantic tests | Review |
|---|---|---|---|---|
| CC-E01 | The correct PCP, specialist, other provider, or community organization is unknown. Requires the need, candidate identities, source directories, effective dates, service area, and patient-provider relationship evidence. | L0 may retrieve candidates; L1 may verify administrative identity and endpoint; L2 facilitates beneficiary choice. No PHI release or clinical-suitability inference until the recipient is verified. | Hold affected release. Resolves the routing obligation only with verified identity/endpoint and beneficiary selection where applicable; parent case is re-evaluated. Test same-name providers, moved practice, inactive NPI, wrong specialty, and no safe match. | |
| CC-E02 | The verified recipient has no usable electronic endpoint. Requires recipient, permitted channels, endpoint attempts, disclosure basis, packet version, and channel capabilities. | Apply the applicable settled channel/release matrix. L1 may verify fallback facts and prepare; for an ordinary nonclinical community referral, the assigned Puerto Rico GUIDE navigator performs the new exact V1 release check under D-007, with the designated Puerto Rico navigator lead as backup. Other Care Coordination release classes remain controlled by O-021. Absence of an electronic endpoint does not authorize a new channel by default. | Keep the recipient obligation open through bounded fallback attempts. Transmission alone is not receipt/access or parent closure. A corrected endpoint or re-send receives a new exact V1 release event. Test fax, mail, portal without access, bad number, changed endpoint, assigned-navigator unavailability, and backup release. | |
| CC-E03 | A release or request occurred but the required receipt/access event is absent or unknown as of the evaluation time. Requires the exact release event, recipient, channel, clock origin, and matching acknowledgments. | Unknown remains unknown. L0 may detect and task; L1 may pursue administrative status; retry/exhaustion policy is blocked by O-004/O-020/O-021. | Escalation or retry resolves no parent outcome. Close only this pursuit obligation when the approved receipt/access evidence or an authorized non-success disposition exists. Test late ack, wrong-version ack, explicit rejection, no response, and duplicate ack. | |
| CC-E04 | The recipient reports that the patient is unknown or identifiers do not match. Requires the released/requested packet, identifiers used, recipient response, prior identity evidence, and any disclosure already made. | Freeze further release and invoke X-001; L1 captures the response without guessing; L1 verifies objective identity/endpoint facts; L2 enters only for a D-021 relationship issue. Software applies the approved exposure/incident rule; Healthcare Legal Counsel enters only for a genuine uncovered legal question. | Do not merely rerun matching after a possible wrong-recipient disclosure. Resolve with corrected identity/routing, exposure disposition, and affected-party actions; parent case then re-evaluates. Test wrong patient, wrong practice, stale roster, false denial, and PHI already sent. | |
| CC-E05 | A referral destination rejects the referral. Requires destination, referral scope, rejection source/reason, clinical/administrative classification, and beneficiary choice. | End that destination attempt. L0 may retrieve alternatives; L1 verifies administrative rejection facts; L2 presents approved alternatives; a clinician decides any clinical withdrawal or changed need. | Rejection is not parent closure. Continue with beneficiary-selected alternative or end truthfully as refusal, authorized cancellation, external unavailability, or transfer. Test clinical rejection, insurance/eligibility denial, capacity limit, wrong provider, and no alternative. | |
| CC-E06 | A provider/resource is unavailable or offers a waitlist. Requires availability source/time, expected wait, urgency, alternatives, beneficiary preference, and barrier facts. | L0/L1 may verify availability and alternatives; L2 supports the beneficiary's choice; clinical urgency is decided by the authorized US path. | An accepted waitlist remains open unless settled policy permits a named non-success disposition. Test beneficiary accepts wait, selects alternative, urgency changes, indefinite wait, and listing later proves stale. | |
| CC-E07 | Cost, coverage, transport, language, accessibility, geography, technology, or caregiver logistics block access. Requires the actual barrier, source, proposed supports, funding responsibility, and beneficiary preference. | L0 may match deterministic support facts; L1 implements approved logistics; L2 and the beneficiary choose among feasible options; clinical staff address safety/clinical consequences. | A documented barrier is not successful connection. Resolve the barrier obligation with a feasible accommodation or a truthful non-success/risk disposition; re-evaluate the parent need. Test multiple barriers, no funding, inaccessible site, interpreter unavailable, and beneficiary refusal. | |
| CC-E08 | An appointment is missed, cancelled, disputed, or reported differently by parties. Requires appointment/encounter IDs, source events, reason, outreach, urgency, and beneficiary intent. | L0 detects discrepancy; L1 verifies status and may schedule within approved constraints; L2 addresses refusal/confusion or changed preference; clinical staff address risk. | Rescheduling is not referral completion. Resolve with a new appointment, confirmed encounter, or typed non-success disposition. Test provider cancellation, beneficiary no-show, transport failure, duplicate appointments, and encounter claimed by only one source. | |
| CC-E09 | A specialist encounter occurred but no correctly matched visit documentation has returned. Requires encounter evidence, expected document class, custodian, requests, received candidates, and as-of time. | L0 detects the missing matched artifact; L1 pursues already-authorized records; authorized clinical staff reconcile only after identity/integrity checks. | The specialist loop stays open under D-009. Document receipt alone is insufficient until matched and reconciled. Test no note, wrong encounter, partial note, unsigned note, late note, and explicit no-record response. | |
| CC-E10 | An outside party asks an administrative worker a clinical question. Requires the verbatim question, source identity, affected beneficiary/case, urgency signal, and any prior approved response. | Administrative work stops on the clinical content. L1 captures verbatim; deterministic routing sends it to the role authorized under O-003, not automatically to an RN. | No improvised answer or administrative relay. Resolve the question obligation with verified source, authorized response/disposition, exact released communication, and resulting child work. Test routine admin question, mixed admin/clinical content, urgent symptom, medication question, and unclear identity. | |
| CC-E11 | L0/L1 receives a possible new clinical instruction, order, recommendation, or medication change. Requires raw content, source/identity, receipt channel/time, affected case, and confidence/verification state. | A candidate signal is enough to impose a safe block; it is not enough to act. L1 records verbatim and stops; the appropriately authorized clinician verifies and dispositions it. | Do not interpret or relay the instruction to the beneficiary. Resolve with verified authority, clinical classification, lawful disposition, exact approved communication, and linked plan/medication events. Test false positive, wrong patient, unauthenticated sender, urgent order, and superseded instruction. A current authenticated scope-matched referral or clinical product may be linked and reused; new protected judgment occurs only when its basis is absent, disputed, changed or insufficient. Test existing current referral order versus stale/different question. | |
| CC-E12 | PCP and specialist recommendations conflict. Requires each verbatim recommendation, provider identity/authority, dates, affected elements, supporting evidence, and prior plan state. | Preserve both; do not choose by recency alone. L1 may request existing records only; L2 coordinates; L3/L4/L5 resolve within actual authority under O-003. | Withhold affected instruction until authorized disposition. Resolve with the chosen course, rationale, retained dissent/conflict, required provider notifications, and plan/medication effect. Test partial conflict, no response, equal authority, superseded recommendation, and beneficiary refusal. | |
| CC-E13 | A potentially urgent need exists and the ordinary office/path is unresponsive. Requires the actual symptom/safety facts, source, time, attempted contacts, and current location. | Urgency is not selected by L1 or AI. Invoke the approved US clinical/safety pathway under O-004; P0 behavior follows X-008. | Identifying an urgent destination or completing a safety handoff does not close the coordination case. Confirm handoff and retry failure. Test closed office, disconnected call, uncertain location, caregiver panic, false alarm, and post-terminal signal. D-026 human first answer does not establish continuous Puerto Rico or in-house clinical availability. O-054 must approve the actual receiving route/hours/backup/failure disposition; L1/L2 never decide safe morning delay. Test explicit emergency during packet hold and 2 a.m. medical question without an approved clinical route. | |
| CC-E14 | A transition is known but discharge/transfer information is missing. Requires matched episode, from/to setting, event times, current status, requested records, and known medication/follow-up facts. | L0/L1 pursue existing records; L2 provides support; an authorized clinician may establish a safe provisional course within scope. Missing data cannot be treated as no change. | A safe provisional plan permits care but is not proof of document receipt or transition completion. Resolve records and resulting obligations or use only a pre-existing authorized exception. Test no summary, partial AVS, weekend discharge, wrong encounter, and safety concern. | |
| CC-E15 | Transition information arrives late, is corrected/retracted, or conflicts with actions already taken. Requires original and new events, observed/received times, correction relation, prior actions, and terminal status. | Preserve both event histories; authorized clinical staff compare material differences; L0 must not silently overwrite. | Correct unsafe divergence and open child work. If the prior case is terminal, append provenance and open a linked successor when action is needed; never rewind it. Test late ADT, retracted discharge, changed medication list, duplicate event, and no material difference. | |
| CC-E16 | Two referrals/requests appear duplicative. Requires need, destination, question/scope, ordering source, event IDs, time, and reason for possible parallel work. | L0 flags and blocks accidental duplicate execution; L2/clinical owner determines whether simultaneous referrals are intentionally distinct. Never discard a unique need merely because fields resemble another case. | Exact duplicate adds provenance only; justified parallel cases retain their separate rationale and obligations. Test corrected referral, two specialties, same specialty/different question, retry duplicate, and duplicate after terminal. | |
| CC-E17 | GUIDE and Medicaid services appear overlapping. Requires both dated service inventories, payer, provider, frequency, scope, actual delivery, and responsibility. | Distinguish duplicate delivery, duplicate payment, overlapping responsibility, a true service gap, and complementary services. L2/Medicaid case manager coordinate; billing/compliance handles payment risk. | Resolve with a responsibility matrix and assigned actions; do not terminate beneficial complementary support. Test same service/different payer, partial overlap, conflicting case managers, uncovered gap, and stale inventory. | |
| CC-E18 | A community organization has no API or electronic workflow. Requires verified organization/endpoint, intake method, required forms, release basis, and manual attempt events. | Create the approved manual pursuit path. L1 may perform permitted administrative calls/forms. The service seeker chooses; software records a clear authenticated choice; L2 performs only a requested or required human connection or relationship act. Lack of an API does not lower identity, privacy, receipt, or connection evidence. | Resolve with the same route-specific connection or truthful non-success outcome as an electronic path. Test phone-only intake, paper form, voicemail, no callback, changed requirements, and inaccessible modality. | |
| CC-E19 | A beneficiary, caregiver, or representative refuses or withdraws from an action. Requires speaker identity, decision-specific authority, beneficiary capacity/choice, exact refused element, explanation source, and time. | Apply X-002/O-011. L2 authenticates and records choice; clinical staff explain clinical consequences/alternatives when required; caregiver refusal is not automatically controlling. | Stop only the affected action; retain informed refusal, alternatives, safety response, and resulting plan. Test capable beneficiary versus caregiver, partial refusal, representative conflict, later change, and immediate risk. | |
| CC-E20 | PCP, residence, location, service area, or care setting changes during an open case. Requires old/new facts, effective/awareness times, source, pending and in-flight releases, alignment status, and open obligations. | Invalidate unsent routing and endpoint assumptions; do not redirect an already released packet. Software rebuilds factual routing; L1 repairs endpoints and L2 performs only triggered relationship work. Approved disclosure/incident controls address in-flight exposure; the exact Program Operations status task handles residence/alignment consequences. | Resolve the changed routing/status obligation and rebuild applicable work. The parent case closes only on its manifest. Test PCP change before/after send, move out of area, temporary stay, unknown date, and conflicting sources. | |
| CC-E21 | Outside-PCP care-team membership is unknown, the PCP cannot be identified, the PCP has access only to a superseded plan, or notification/access exists without resolution of an applicable coordination need. Requires current PCP, membership period, active plan version, prior access, coordination need/request, and source evidence. | Hold the satisfaction claim; L0/L1 pursue identity and endpoint facts; L2 confirms the care relationship and coordinates; policy is controlled by O-020/O-021. | No old-version, “portal exists,” or notification-plus-access inference proves complete coordination. Resolve with current membership/PCP, route-specific coordination outcome, and active-version access evidence, or a truthful authorized non-success disposition. Test no PCP, multiple PCPs, PCP refuses coordination, PCP requests follow-up, no current coordination need, changed PCP, old plan, and inaccessible portal. | |
| CC-E22 | PCP referral notice fails, active co-management is unknown, or consultation does not occur. Requires PCP, referral, notice attempts, co-management evidence, consultation request/response, and urgency. | Preserve mandatory PCP notice separately from specialist packet receipt. Apply the settled consultation policy after O-020; unknown co-management cannot default to false. | Specialist receipt alone cannot satisfy the PCP obligation. Resolve each applicable obligation or end with an authorized non-success disposition that does not claim fulfillment. Test PCP on team, outside PCP, co-manager yes/no/unknown, refusal, and urgent referral. Reuse a current attributable PCP consultation covering the same referral/question; office acknowledgement or old involvement is not substantive consultation. Preserve the RFA's should wording once co-management is established; test PCP-authored referral versus generic receipt and materially changed rationale. | |
| CC-E23 | A new-provider introduction is requested but incomplete, refused, delayed until after the visit, opposed by the capable beneficiary, or assigned to someone who is not an approved care-team member. Requires request, verified beneficiary or GUIDE-caregiver status, time, provider/newness, assigned actor, modality, separate disclosure basis, any beneficiary conflict, and outcome. | Verified beneficiary or GUIDE-caregiver status can trigger the introduction without representative authority. L2 or another approved care-team member performs it under O-021; L1 is not presumed eligible. Evaluate representative authority separately only for provider selection, treatment decisions, or another act that requires it. | REQUESTED cannot become not applicable through nonresponse. Resolve with completed introduction, withdrawn request, capable-beneficiary conflict disposition, provider refusal, or explicit failed disposition and next plan. Test non-representative caregiver request, unverified caregiver, capable beneficiary objection, late request, async message, and failed warm handoff. | |
| CC-E24 | Returned specialist/transition material is partial, illegible, corrupt, wrong-patient, wrong-encounter, unsigned, internally inconsistent, or contains an unverified instruction. Requires artifact source, patient/encounter match, document status, and affected recommendations. | Quarantine the defective material from satisfaction. L0/L1 may pursue corrected records; approved software incident controls address wrong-patient exposure, with the exact legal exception routed only when uncovered; clinical staff review only validated content. | Do not close documentation or reconciliation obligations. Resolve with corrected/validated material or an authorized non-success disposition. Test each defect plus mixed valid/invalid pages and later correction. | |
| CC-E25 | A specialist referral ends without an encounter because of refusal, cancellation, clinical withdrawal, loss to follow-up, death/status change, or beneficiary-chosen indefinite wait. Requires reason, actor/authority, attempts, alternatives, risk, and communication. | Do not demand nonexistent visit documentation, but do not claim D-009 successful loop completion. L2/clinical owner selects only an allowed non-success disposition under O-019. | Parent may end truthfully with unsatisfied obligations, risk treatment, and next plan. Test each reason, disputed encounter, late visit, and re-referral after terminal. | |
| CC-E26 | A direct community referral/list was sent but connection is not evidenced, acceptance did not lead to intake/service, or an AAA/Tribal agreement-route handoff lacks evidence of assistance/outcome. Requires route, need, resource/agency, current agreement where applicable, referral/handoff, accountable follow-up, responses, intake/start events, barriers, and beneficiary choice. | Keep direct referral, agreement handoff, and route-specific connection/assistance evidence separate under O-022. Software performs the clean tracking path; L1 may pursue missing administrative status; the service seeker chooses; For an ordinary person-specific community referral, preserve the actual paid D-007 assigned-L2/approved-lead release/initiation once; §6.3 navigator referral applies to assessed HRSN resources, separately from §6.1 written partner assistance. L2 performs only any additional triggered human connection, warm introduction, disagreement, distress, or relationship follow-up. | SENT, accepted referral, scheduled intake, or agreement handoff does not automatically satisfy the route. Test directory-only, direct service start, accepted then stalled, current agreement with completed assistance, handoff without follow-up, expired agreement, and beneficiary refusal. | |
| CC-E27 | The community inventory is stale, out of area, conflicted, inaccessible, or has no accountable owner, or the relied-on AAA/Tribal agreement is absent, expired, or outside scope. Requires inventory/agreement source and version, verification/effective dates, coverage, update history, and affected candidates. | Block claims of current availability or valid agreement-route coverage; retrieve/verify alternatives; owner, freshness, agreement, and route policy are controlled by O-022. | Do not present a stale listing or expired agreement as an available route. Resolve with a current verified candidate/agreement and route-specific outcome, or a documented gap/non-success disposition. Test closed organization, expired agreement, changed eligibility, duplicate listings, missing accessibility data, and no owner. | |
| CC-E28 | Medicaid eligibility, HCBS eligibility, or current receipt of HCBS is missing, stale, or conflicted. Requires each status separately, program/waiver, effective period, and sources. | Do not trigger or suppress the HCBS obligation from dual eligibility alone. L0/L1 pursue administrative evidence; L2/Medicaid operations resolves under O-023. | Maintain an applicability hold until established. Test eligible-not-receiving, receiving-unverified, conflicting sources, ended waiver, and new enrollment. | |
| CC-E29 | The HCBS case manager is missing, changed, refuses coordination, disputes identity, or does not respond. Requires manager/program identity, endpoint, attempts, responses, and service inventories. | L0/L1 verify and pursue; L2 owns coordination; attempt/retry/exhaustion and monitoring are controlled by O-023/O-004. | ATTEMPTED_NO_RESPONSE may record the fact but not a joint review. Resolve through verified contact/joint review or an authorized non-success disposition with continued-risk plan. Test changed manager, no assignment, wrong program, refusal, and late response. | |
| CC-E30 | GUIDE/Medicaid comparison reveals a gap, duplicate, contradictory instruction, or disputed responsibility. Requires dated inventories, finding type, affected service/person, payer/provider, and each party's position. | Create an owned action for every finding; L2 coordinates; clinical, compliance, or billing authority handles its domain. Do not let the case manager's administrative response decide clinical or payment policy. | Resolve with responsibility, follow-up, beneficiary communication, and care-plan effect. Test gap with no provider, complementary services, duplicate payment risk, conflicting frequencies, and unresolved dispute. | |
| CC-E31 | Transition setting, direction, timing, duration, or residence type is ambiguous. Requires facility/unit/bed, from/to setting, event and awareness dates, expected/permanent status, and source conflict. | Enter a classification hold; L0/L1 gather source facts; L2/status owner verifies; no AI or facility-name inference decides RCC, memory care, hospice, or long-term nursing status. | Continue only safe support while withholding unsupported status/billing conclusions. Resolve with dated classification and applicable branch. Test ED observation, short SNF, assisted living campus with memory unit, swing bed, and unknown permanence. | |
| CC-E32 | An already aligned beneficiary moves to an RCC, a Memory Care Unit, hospice or long-term nursing residence. Requires exact facility/unit/bed, awareness and effective dates, separate current CMS RCC approval and compliant-arrangement facts, actual CMS/Agreement basis, BAR and open care needs. | For an RCC, known No/No enters the public PMP §2.12 60-day awareness-based period; Yes/Yes uses the ordinary route. Mixed Yes/No and No/Yes have no express 60-day grant and incomplete ordinary prerequisites; obtain the exact Agreement/CMS disposition under O-024/O-PA-001. Unknown or expired facts are pursued, not treated as false. Participant transition permission never authorizes unapproved RCC Partner delivery. Keep the 15-day Memory Care Unit path separate. | Continue independent authorized support/safety work while holding only unsupported RCC status/service/billing decisions. Close with the approved disposition, actual transition/planning assistance, required PAAF/CMS result, effective billing dates and disposition of open care. Test all four known combinations, unknown/conflicting/expired status, delayed/corrected awareness, either prerequisite achieved first, day 60 with approval alone pending, ordinary return, memory care, hospice and temporary versus permanent nursing residence. | |
| CC-E33 | A case has coordination activity but the claimed GUIDE service is automation/infrastructure only, outside alignment, performed by an unapproved organization, or unsupported by applicable cadence/evidence. | Case closure and service gate remain separate. Compliance/billing decides under O-009/O-025; L0 cannot promote administrative evidence into a qualifying service. | Record NONQUALIFYING or NOT_EVALUATED_BLOCKED without changing the case outcome. Test open-case qualifying service, closed-case nonqualifying activity, L1 chase only, Partner status, and date outside alignment. | |
| CC-E34 | A terminal outcome is attempted while one or more applicable obligations or resulting child actions remain unresolved, or evidence belongs to another case/version/recipient. Requires closure manifest, obligation applicability, evidence links, and proposed outcome. | Invoke X-015; block success. L0 may identify gaps; the evidence owner resolves; no narrative note or local edge resolution substitutes for the missing obligation. | Remain open or select only an authorized non-success outcome with exact unsatisfied obligations. Test missing PCP notice, open medication action, wrong note, waitlist, and completed safety handoff with parent work open. Separate attributable professional product, parent manifest and each child service result. Missing evidence prerequisite to today's clinical judgment prevents successful product; future pending results do not erase a completed product. Medication case creation is not §5.4 reconciliation. Test reviewed referral with future test open, reconciliation opened/no product, and home-health acceptance/no visit. | |
| CC-E35 | Decision authority or disclosure permission changes after preparation, approval, release, or while a packet/action is in flight. Requires basis, scope, effective time, recipient, queued/released work, and independent bases. | Apply X-002; cancel controllable dependent work, preserve already-sent facts, and re-evaluate each action. Approved software enforces the established legal-basis/revocation rule; L0/L1/L2 do not decide uncovered legal effect. Healthcare Legal Counsel receives only a complete genuine legal exception. | Do not claim to recall a sent packet. Resolve with basis decision, cancellation/access evidence, exposure review, rebuilt obligations, and beneficiary choice. Test partial revocation, changed representative, independent treatment basis, and change after receipt. | |
| CC-E36 | Duplicate, late, corrected, or materially new evidence arrives after a terminal coordination outcome. Requires old/new event IDs, event/receipt times, correction relation, prior terminal snapshot, and materiality facts. | Preserve terminal immutability. Exact duplicate attaches provenance; corrected or new material evidence opens a linked successor when action is required. The actual licensed professional resolves protected clinical meaning; L2 handles only a triggered relationship question. | Never mutate or “reopen” the old case. Test duplicate note, corrected wrong-patient event, material recommendation, late no-change note, and attempted old-case transition. Objective duplicate handling is software work; protected clinical meaning routes directly to its authorized professional, and L2 enters only for an actual relationship/choice issue. | |
| CC-E37 | A test, laboratory result, imaging result, pathology result, or other clinical item is pending after a transition or referral, but no accountable reviewer or return route is established. Requires the order/result class, ordering and receiving clinicians, expected timing, current status, beneficiary location, and communication route. | Do not treat scheduling, specimen collection, or result availability as clinical review. L0/L1 tracks and retrieves; L2 coordinates; L3/L4/L5 establishes or accepts clinical review responsibility within scope. | Keep the result obligation open until a named authorized reviewer receives and dispositions the result and required communication occurs. Test result never posted, posted but unreviewed, wrong clinician, critical result, patient moved, and late corrected result. A future not-yet-due result with accepted reviewer, timing, return and safeguards stays open without erasing an already completed review; missing evidence needed for today's decision cannot be deferred into a successful product. Test both timing conditions and posted-but-unreviewed result. | |
| CC-E38 | A medication, ordered equipment item, home-health visit, oxygen or other supply, personal-care service, or other transition-critical support is unavailable, delayed, wrong, unusable, or refused. Requires the exact item/service, order/source, expected and actual status, clinical importance, barriers, alternatives, and beneficiary choice. | L0/L1 verifies operational facts; L2 addresses access and choice; L3/L4/L5 determines clinical consequence and any clinical alternative. Missing delivery is not successful transition support. | Preserve the current safe plan and escalate according to clinical importance. Resolve with usable delivery/service, an authorized alternative, informed refusal, or a truthful unresolved outcome with safeguards. Test backorder, wrong equipment, no home-health start, coverage denial, unsafe substitution, and weekend discharge. | |
| CC-E39 | The beneficiary or permitted caregiver cannot understand or use transition or coordination instructions because of cognition, language, hearing, vision, literacy, inaccessible modality, contradictory materials, or unsuccessful teach-back. Requires the exact instruction, source/version, recipient, accommodations, teach-back attempts, misunderstandings, authority, and support options. | Do not document comprehension from delivery or a yes/no response. L2 provides accessible re-explanation and approved support; L3/L4/L5 addresses clinical or capacity implications; privacy/legal authority remains separate. | Withhold a comprehension-complete claim and any unsafe self-execution. Resolve with successful teach-back, an authorized helper or alternative support, or an explicit unresolved risk plan. Test interpreter need, aphasia, hearing loss, old instructions, no caregiver, and repeated failed teach-back. Faithful current approved instruction delivery and direct successful plan-back can complete under the approved mode without default navigator or live clinician. New individualized clinical questions return to the authorized author; test clear direct success versus new medication question. | |
| CC-E40 | A readmission, ED return, transfer, or other new transition occurs before the prior transition work is complete. Requires both events, current location, open medication/results/services/equipment items, actions already taken, and new instructions. | Preserve both episodes and link them; do not overwrite the prior transition or assume its open work is cancelled. L0/L1 reconciles administrative duplication; L2 coordinates; clinicians determine which prior actions remain valid or unsafe. | Stop superseded pending actions when authorized, carry forward still-valid obligations, and open new transition and medication work. Test same-day ED return, readmission after home-health order, transfer to SNF, duplicate ADT, and new discharge before old records arrive. | |
| CC-E41 | A behavioral-health or substance-use referral, record, question, or handoff may include specially protected or segmented information. Requires data class/source, purpose, recipient, legal or permission basis, segmentation, revocation, urgency, and independent treatment bases. | Apply X-002 and approved source-class segmentation/disclosure controls; hold only the affected content. Route a complete genuinely uncovered legal question to Healthcare Legal Counsel, not a routine privacy reviewer. L0/L1/L2 does not infer that ordinary treatment coordination authorizes every use or disclosure; clinical staff states clinical need only within the permitted boundary. | Withhold only affected content while preserving safe permitted coordination. Resolve with lawful-basis and segmentation decisions, authorized release or alternative handoff, exposure disposition, and clinical follow-up. Test Part 2 content, mixed packet, partial consent, revocation, emergency question, and wrong recipient. | |
| CC-E42 | Discharge or transfer occurs without a usable plan because of an against-medical-advice departure, elopement, rushed or after-hours discharge, clinically material same-day ED discharge, missing prescription/order, or unavailable discharging team. Requires setting/event, known instructions, missing elements, current location, symptoms, medication/supply, follow-up, attempts, and responsible clinicians. | Missing plan content cannot become no change. L0/L1 pursues available records; L2 establishes practical facts; L3/L4/L5 creates only the safe provisional clinical direction within actual authority. | Invoke safety review as needed and keep every missing transition obligation explicit. Resolve through recovered or newly authorized instructions, medication disposition, follow-up ownership, accessible communication, and care-plan effect. Test each departure type, wrong discharge list, no prescription, no callback, and rapid deterioration. | |
| CC-E43 | The actual clinical recipient's current physical location (beneficiary or caregiver receiving a separate licensed act) is unknown, changes during contact, or lies outside the proposed clinician's authority for the licensed act. Requires actual clinical subject separately from reporter/caller, subject location source/time and applicable provider-location requirements, travel or temporary-residence facts, proposed act, clinician licenses/privileges, jurisdiction, and safety concern. | L0-L2 may collect facts and connect but may not allow a licensed assessment, triage, reconciliation, treatment decision, or individualized instruction without current authority. A safety connection is not delayed for routine cleanup. | Hold the affected clinical act and route to an authorized clinician or emergency service. Resolve with verified location and authority or an approved alternate pathway. Test caregiver in NY reporting beneficiary in FL; caregiver-own licensed care in NY while beneficiary is in FL; dual-subject separate acts; provider-location conflict; PR-located appropriately authorized clinician/Florida beneficiary, beneficiary traveling in PR, location change mid-call, unknown location with safety concern, and valid license without prescribing authority. |
Medication Management edge cases#
Status: DRAFT semantic register. Existing IDs MED-E01 through MED-E25 retain their original subjects; their evidence, authority, and closure meanings are corrected below. New numeric rule IDs and machine states are deliberately deferred until the semantic SOP set and later fault gates are complete. Numeric urgency, retry, transition, and provider-response clocks remain blocked by O-004/O-005 unless a current CMS deadline is named.
| ID | Trigger, required facts, and provenance | Business gate, permitted automation, and human authority | Communication, fail-safe, objective outcome, and minimum semantic tests | Review |
|---|---|---|---|---|
| MED-E01 | A valid order/e-prescription exists but no matching fill/dispense is observed as of the expected time. Requires order intent/status/effective date, medication identity, PRN/start conditions, pharmacy and claims events/reversals, cash/sample/facility supply, source latency, and access barriers. | L0 may create a missing-supply review condition; L1 verifies pharmacy/administrative status; L2 assesses reported access barriers and choice; a clinician decides clinical significance. No observed fill is not abandonment or nonadherence. | Resolve the source/access obligation with the actual supply outcome, barrier disposition, or retained unknown; re-evaluate the parent case. Test not-yet-due, PRN, cash/sample, partial fill, reversed claim, facility supply, shortage, refusal, and no response. | |
| MED-E02 | A fill/dispense or claim appears without a known matching order. Requires exact patient/product, pharmacy, event type, handoff versus claim status, order searches, source latency, and corrections. | L0/L1 pursue the source/order; no active regimen is inferred. Clinical review is required only if the event affects current treatment/safety after identity is resolved. | Resolve with matched order/source, explicit error/reversal, external-prescriber event, or retained conflict; do not close reconciliation from the fill. Test cash/external order, transferred prescription, reversed claim, wrong patient, sample, and stale EHR. | |
| MED-E03 | A valid apparent dispense/handoff occurs after an authorized stop or deprescribing decision. Requires medication identity, stop author/authority/effective time, order/cancel transmission, pharmacy response, dispense preparation/handoff, reversal, possession/taking reports, symptoms, and receipt times. | Preserve all planes; withhold any new instruction that assumes either regimen and invoke prescribing-clinician review. Urgency derives only from approved clinical facts under O-004, not a universal P1 label. | Resolve the conflict, current regimen, possession/use, pharmacy status, recipient communication, and any safety action separately. Test dispense predating stop but received late, partial fill, claim reversal, mail order, cancel ack, household possession, reported taking, and wrong identity. | |
| MED-E04 | EHR, bottle, pharmacy, beneficiary, caregiver, or facility sources disagree on dose, strength, route, form, frequency, or status. Requires each verbatim/source assertion, time period, authority, and current regimen version. | Preserve every source assertion. Software/direct reports establish source-faithful facts; L1 verifies disconnected labels; L2 enters only a D-021 report/relationship exception. The prescribing-authority clinician dispositions clinical differences; a signature does not erase them. | Recognize the M14/M15 product only from its actual clinician-authored complete or incomplete result. Track EHR/pharmacy/recipient work separately. Test a completed review with future monitoring, one material item unresolved, old label, facility list and late correction. | |
| MED-E05 | Brand/generic names or codes may refer to the same product or a clinically distinct product. Requires source text, ingredient, strength, form, route, release characteristics, compound/pack data, terminology version, and mapping provenance. | L0 may apply only an exact approved terminology mapping. Therapeutic equivalence, substitution, and appropriateness remain clinical. Ambiguous or out-of-scope content stays candidate. | Resolve identity to the supported specificity without declaring a clinical duplicate. Test same ingredient/different strength, immediate versus extended release, salt/form, combination product, ambiguous OCR, and exact duplicate. | |
| MED-E06 | Two medications share an ingredient or therapeutic class. Requires exact products, regimen/indication, prescribers, timing, intended overlap, and source rule/version. | L0 may create a versioned clinical-review condition; it cannot conclude inappropriate duplication. The prescribing clinician determines intentional overlap or clinical disposition under O-035. | Do not auto-stop or message the beneficiary. Resolve with authorized rationale/disposition and resulting change/no-change case. Test intentional combination, transition overlap, cross-titration, same class/different indication, duplicate ingredient, and missing indication. | |
| MED-E07 | PRN frequency, maximum, pill splitting, alternating schedule, or reported use differs from the current order. Requires exact directions, PRN indication/max if available, source reports, use period, ability/barriers, and clinical context. | L2 authenticates the report and barriers; L1 may verify label directions; the prescribing clinician decides safety/current regimen. Navigator does not approve the difference. | Preserve intended schedule and reported use separately. Resolve through reconciliation, change proposal, support, or refusal outcome. Test occasional PRN, unapproved split, intentional taper, alternating days, unclear maximum, and caregiver disagreement. | |
| MED-E08 | Compound or liquid concentration/formulation is unclear or inconsistent. Requires verbatim label, pharmacy/product, concentration/units, ingredients, preparation date, order, photos, and source contacts. | L1 may obtain formulation facts from the verified pharmacy; terminology remains candidate if ambiguous; only the authorized clinician decides the correct dose/use. | Pharmacy-confirmed formulation resolves identity, not clinical dose. Close after formulation and clinical impact are separately dispositioned. Test changed concentration, missing units, multi-ingredient compound, expired preparation, wrong pharmacy, and illegible label. | |
| MED-E09 | An OTC product, supplement, natural treatment, herbal, or other substance is reported or observed. Requires source-faithful identity, product/ingredient/strength if knowable, use pattern, purpose/report, possession, and terminology limitations. | Create a source assertion/candidate; do not force an unsupported RxNorm match. L2 authenticates use; the prescribing clinician includes it in the §7.1 review and determines clinical significance. | Resolve identity/use to the supported level, retain unknown components, and record clinician reconciliation/change/no-change. Test multi-ingredient supplement, natural product out of RxNorm scope, intermittent use, old bottle, caregiver-only report, and refusal to disclose. | |
| MED-E10 | A physician sample is reported or photographed. Requires product, lot/label if available, source clinician, quantity, date, intended directions, possession, and current-use report. | L0/L1 may pursue product/source evidence; the photo proves a labeled container/possible possession, not an order or taking. The prescribing clinician reconciles impact. | Resolve supply, intended regimen, reported use, and future access separately. Test old sample, unlabeled sample, no EHR order, different strength, exhausted supply, and caregiver photo. | |
| MED-E11 | Facility, infusion, Part B, or other administration-related evidence appears. Requires event/claim/MAR type, setting, encounter, administrator, dose/time, order, claim status, and continuation instructions. | A claim is not administration. L0/L1 pursue the matched MAR/record where needed; an observed administration applies only to that event; clinician determines ongoing regimen. | Resolve the administration episode and continuation plan without extrapolating home use. Test claim without MAR, wrong encounter, injection series, one-time dose, facility transfer, reversed claim, and missing discharge direction. | |
| MED-E12 | Pre-event, facility/discharge, pharmacy, and current household regimens conflict after a transition within the current Participation Agreement's applicable class. Requires matched transition, each source list/event, setting/effective times, current reports, and linked care-plan facts. | Open TRANSITION_RECONCILIATION; do not choose the newest list by default. L0/L1 gather; L2 authenticates reports; the role authorized by the current Participation Agreement and settled O-028 transition taxonomy reconciles without exceeding scope. Prescribing-authority requirements still apply when §7.1-7.4 applies. | Close only with the transition medication manifest, route-specific actor authority, and linked Care Coordination disposition; late material evidence opens linked work. Test hospital-to-home, ED only, SNF, missing summary, changed order, late MAR, no caregiver, and transition work that is or is not also a §7.1 review. | |
| MED-E13 | Several prescribers appear responsible, or medication/indication ownership is unclear. Requires providers, orders, treatment relationship, indication, co-management, responsibility statements, effective dates, and acceptance. | Software reuses an approved current clinically determined provider basis; L1 verifies administrative relationships. The proposing clinician resolves actual clinical-applicability or responsibility uncertainty under O-029; outside providers accept/dispute their own responsibility. Sharing and agreement lists remain separate. | Hold agreement routing until the agreement authority is established while preserving each applicable sharing obligation; retain disputes/multiple responsibility. Test GUIDE clinician is PCP, share-only specialist, one of several agreement authorities, transferred care, provider left practice, shared management, and no provider accepts. | |
| MED-E14 | Fills appear early or create apparent stockpile. Requires order/directions, quantities/days supply, partial fills, reversals, schedule changes, travel, automatic refill, facility/sample supply, possession, and use reports. | Do not infer overuse. L0 detects; L1 verifies source facts; L2 authenticates explanation/barriers; clinician handles safety if triggered. | Resolve explanation, possession/access, and safety outcome separately. Test dose decrease, vacation override, auto-refill, partial fill, nonpickup, mail order, intentional reserve, and unexplained pattern. | |
| MED-E15 | Fill appears late or a gap is detected. Requires expected use assumptions, PRN status, dose changes, hospitalization/facility, samples/cash fills, reversals, shortage, cost/coverage, possession, and reported use. | Do not infer nonadherence. L1 verifies supply facts; L2 addresses barriers/reports; clinical staff assess only when indicated. | “Reason known” is not enough if access or safety remains unresolved. Close the scoped barrier/discrepancy with current regimen and follow-up. Test hospitalization, sample, PRN, stopped medication, shortage, cost, refusal, and unknown. | |
| MED-E16 | Beneficiary and caregiver/representative reports differ. Requires each report, identity, decision-specific authority, beneficiary capacity facts, time, medication/schedule, and independent sources. | Preserve both attributable reports under X-002/O-011. Direct authenticated reports do not require L2 by default; L2 handles only actual relationship/authority-help needs. Caregiver disagreement is not an automatic veto; prescribing clinician determines clinical content. | No global reliability/capacity inference. Resolve with controlling decision/authority, retained dissent, current regimen/report states, and permitted communications. Test capable beneficiary, valid representative, unverified caregiver, partial disagreement, fluctuating capacity, and later correction. | |
| MED-E17 | No caregiver exists, self-report evidence is insufficient, or medication support may be needed. Requires caregiver status separately from capability, source sufficiency, current regimen, support needs/preferences, and safety facts. | Do not invent a proxy or equate no caregiver with unreliability/incapacity. Continue the capable-beneficiary path; L2 offers only supports chosen by the beneficiary or an established decision-specific authorized representative; clinical staff create a safety plan only within authority. | Resolve source insufficiency, §7.5 schedule-support information, medication-access support, and safety obligations separately under O-013/O-033. Test capable beneficiary alone, valid representative, unsupported reliability concern, facility administration, emerging risk, declined support, and later caregiver identification. | |
| MED-E18 | A symptom, fall, confusion, sedation, self-change, suspected error, or other event occurs after or around a medication event. Requires verbatim report, reporter, onset, event/use timing, current context/location, medications, uncertainty, and handoff attempts. | Preserve a possible safety report, not medication causality. Stop only the affected action under approved policy and invoke the exact configured clinical/emergency response; L0/L1/L2 never triage. D-026's Philippine nonclinical human line does not itself establish continuous U.S. clinical or Puerto Rico coverage; O-004/O-032/O-054 govern the actual route and failed-connection behavior. | Record accepted connection separately from returned professional/emergency disposition and resulting work. Lack of packet-release authority holds the packet, not an already approved emergency connection. No approved route means design-blocked, not an ad hoc destination. Test before first dose, unrelated event, uncertain timing, failed transfer, accepted transfer/result pending, and post-terminal signal. | |
| MED-E19 | A performance measure, Beers/anticholinergic, interaction, dose, or other “high-risk” match occurs. Requires exact source/rule/version, medication facts, eligibility, exclusions, clinical context, and unknown inputs. | The current CMS DAE measure is claims-based performance measurement, not an individual stop rule. Any CDS match creates only a clinician-review condition under O-035; clinical advisability remains human. | No automatic deprescribing or risk statement to the beneficiary. Resolve with authorized review/no-change/change and source-specific evidence. Test two fills versus actual use, measure exclusion, stale list, missing diagnosis/lab, false duplicate, and rule version change. | |
| MED-E20 | A clinical rule says existing renal/hepatic/lab or other data are required, but the result is missing, stale, wrong-unit, preliminary, corrected, or mismatched. Requires the approved rule/version, exact data need, source/result/specimen times, units, patient, correction state, and proposed action. | L1 may retrieve already-existing authorized results only; it may not order/select tests. Missing data cannot satisfy a negative guard. The authorized clinician decides testing/clinical action and any pre-existing exception. | No dose conclusion from absent or invalid data. Resolve with valid current data or a structured authorized exception with safeguards/expiry under O-028/O-035. Test every defect and exception expiry before instruction. | |
| MED-E21 | A recommended change requires relevant-provider agreement but the provider declines, modifies, is unreachable, or does not respond. Requires exact proposal, relevant provider set/basis, request/receipt, authenticated response, attempts, and current regimen. | Silence/timeout/office staff is never agreement. MODIFIES creates a new proposal; clinician-to-clinician escalation follows O-005/O-029; L1 pursues administrative status only. | The proposal remains inactive until its exact required agreement is established. End pursuit truthfully as agreed, modified/new proposal, declined, withdrawn or concurrence not obtained. The clinician identifies the applicable current instruction/safeguard; nonclinical staff do not infer that an old regimen is safe to continue. Test wrong provider/scope/proposal, multiple providers, modification, revocation and exhausted approved attempts. | |
| MED-E22 | The beneficiary reports independently starting, stopping, changing, or refusing a regimen. Requires authenticated report, exact action/time/reason, current order/regimen, symptoms, decision authority, and any external clinician involvement. | Preserve as reported use and invoke the appropriate reconciliation/safety path; do not treat it as retrospective agreement or authorized implementation. Numeric same-day/P1 labels remain blocked by O-004. | Beneficiary choice/refusal remains distinct from clinical advice. Resolve with authorized clinical disposition, current regimen/report, safety, communication, and follow-up. Test capable refusal, side effect, misunderstanding, external order, partial change, and caregiver conflict. | |
| MED-E23 | A CancelRx or other cancellation message lacks acknowledgment or appears acknowledged without downstream alignment. Requires stop/order, message/recipient, technical and pharmacy responses, dispense/handoff after cancel, possession/use, retries, and source times. | L0/L1 may retry/verify administrative status under O-031; no acknowledgment is unknown; acknowledgment does not prove no further dispense or household stop/disposal. Clinical conflict routes to prescriber. | Resolve pharmacy execution, current regimen, possession/use, and recipient communication separately. Test technical ack only, rejection, delayed fill, transferred prescription, remaining stock, duplicate cancel, and outage. | |
| MED-E24 | Medication evidence may belong to the wrong beneficiary, encounter, provider, pharmacy, or source. Requires identifiers, match provenance, source event, any disclosure/use, and conflict. | Block wrong-person association/action under X-001. Software/L1 verifies objective identity first; clinical meaning goes only to the exact authorized professional. Apply approved exposure/incident controls in software; System Administration repairs actual access/configuration failures, and Healthcare Legal Counsel enters only a mandated or genuinely uncovered legal question. | Resolve identity, correction, exposure disposition, and affected case. Test similar names, merged chart, wrong encounter, cross-facility ID, pharmacy family member, and clinically valid but wrong-patient content. | |
| MED-E25 | Medication information is segmented, specially protected, or subject to disputed access/use/disclosure. Requires data class/source, legal/permission basis, purpose, recipient, segmentation, revocation, and independent bases. | Approved disclosure/access rules apply in software under D-024. Missing facts route to their actual permitted collector; complete facts not covered by policy hold the affected act and reach Healthcare Legal Counsel or the specifically required approved legal authority. Clinical need does not create permission, and no routine Privacy/Compliance specialist is invented. | Withhold only affected use/disclosure; preserve existence/metadata only as permitted. Resolve with lawful-basis decision, access controls, exposure disposition, and clinical follow-up. Test Part 2, state restriction, partial consent, revocation, emergency question, and mixed data. | |
| MED-E26 | A source event is late, corrected, retracted, reversed, duplicated, or superseded. Requires original/new event IDs, event/received times, relationship, prior decisions/instructions, and terminal status. | Preserve both histories. Exact duplicate links provenance without replay; reversal/correction changes the eligible evidence prospectively; clinical impact routes by approved policy. | Correct unsafe divergence. If a prior case is terminal, append provenance and open a linked successor when material; never rewrite it. Test claim reversal, corrected dose, stale order, duplicate dispense, future-dated event, and no-material-change correction. | |
| MED-E27 | The PCP/applicable-specialist recommendation-sharing recipients or the relevant-provider agreement authority is unknown, disputed, no longer treating, or multiple providers disagree about responsibility/change. Requires separate sharing and agreement manifests, provider relationships, medication/indication scope, orders, responsibility statements, responses, and effective dates. | Apply O-029's separate sharing and agreement rules. Software reuses an established current professional basis; L1 verifies factual relationships. The proposing clinician resolves real clinical applicability/responsibility uncertainty; providers respond within actual scope. Workflow assignment cannot impose outside responsibility. | Hold implementation/instruction until the agreement manifest and response policy are satisfied, while tracking every sharing obligation independently. Test share-only specialist, same GUIDE/PCP, multiple agreement authorities, transfer, disagreement, one silent provider, and no accepted owner. | |
| MED-E28 | A provider response is ambiguous, wrong-scope, wrong-version, stale, modified, declined, or later revoked. Requires exact proposal/version, responder identity/credentials/org/scope, response/effective time, and subsequent evidence. | Only exact current AGREES can satisfy the matched obligation. Modification creates a new proposal; revocation invalidates dependent future actions; GUIDE clinician reconciles. | Cancel/withhold controllable dependent instruction/execution; do not pretend to recall completed actions. Test office staff, old proposal, partial agreement, conditional response, later revocation, and two providers responding differently. | |
| MED-E29 | An authorized regimen fails to synchronize across EHR, care plan, pharmacy, beneficiary schedule, caregiver/facility schedule, or other clinician. Requires exact regimen/order, each destination/recipient, commands/releases, acknowledgments, failures, and prior active version. | Keep destination obligations independent under O-030/O-031. Preserve the attributable M14/M15 product while communication/execution remains open. Software performs approved faithful updates; L1 repairs disconnected facts; the exact approved release person enters only for the required release. No blanket L2 or new clinician review. | No overall synchronization claim from partial success. Record each destination's actual result and next action while the clinician-authored current instruction/proposal status stays explicit. Test completed review/EHR fail, Care Plan success/pharmacy pending, old reminder, caregiver delivery failure and recovery. | |
| MED-E30 | Medication instruction is queued/sent to a wrong or revoked recipient, fails delivery, is inaccessible, or uses a superseded regimen. Requires recipient/authority/permission, exact content/regimen, release, channel, delivery/access, revocation/supersession, and any exposure. | Stop controllable affected work and apply X-002/X-007 plus the approved exposure rule. L1 verifies factual endpoint/delivery; clinical conflicting instructions return to the exact authorized clinician. A mandated/uncovered legal question reaches Healthcare Legal Counsel under the approved roster, not a generic privacy case worker. | Do not infer understanding or implementation. Resolve with correct authorized release/delivery, supersession/cancellation evidence, exposure disposition, and beneficiary safety follow-up. Test no caregiver, unauthorized caregiver, valid representative, revocation before/after send, wrong language, and old version. | |
| MED-E31 | A medication was stopped/cancelled but may remain possessed, accessible, reportedly taken, administered, or undisposed. Requires clinical stop, pharmacy events, supply/possession, reporter, storage/access, taking/administration, disposal facts, and safety context. | Stop/cancel never mutates possession/use. Software/direct reports preserve household/facility facts; L1 verifies a disconnected supply fact; L2 supplies only chosen/needed practical support. Exact authorized professional gives safety/clinical direction; L1/L2 does not improvise disposal or medication-change advice. | Resolve each fact and communication/safety obligation under approved policy. Test cancel ack with stock, facility supply, caregiver administration, disposal unknown, lockbox, and later use report. | |
| MED-E32 | Partial/emergency/trial fill, backorder, shortage, substitution, transfer, return-to-stock, mail-order issue, or claim reversal changes the apparent supply. Requires exact product/form/strength, quantity, days supply, pharmacy event, claim/handoff, replacement, and current regimen. | L0/L1 classify/verify administrative events; therapeutic equivalence or regimen change requires clinician authority; L2 addresses access choice/barriers. | Do not treat a claim or preparation as possession. Resolve supply/access, clinical impact, recipient communication, and follow-up separately. Test each event plus wrong strength, transferred pharmacy, and replacement prescription. | |
| MED-E33 | Taper, cross-titration, PRN maximum, alternating schedule, intentional multiple strengths, or conditional hold is flattened into duplication or one static schedule. Requires full directions, phases/effective dates, indication, current phase, source clinician, and reported use. | Preserve the structured conditional regimen; L0 may detect ambiguity but not simplify; L2 may render only approved content; clinician resolves clinical meaning. | No duplicate alert or reminder schedule may overwrite intended phases. Resolve with current phase, future conditions, recipient comprehension/support, and versioned changes. Test overlapping taper, alternating days, PRN, hold parameters, multiple strengths, and late phase transition. | |
| MED-E34 | Required reconciliation cannot be completed because prescribing-authority evidence is invalid, beneficiary is unreachable/declines, actual-use evidence remains unavailable, or required categories are incomplete. Requires trigger, attempts, category manifest, source gaps, actor credentials/scope, refusal/authority, safety, and prior regimen. | Do not route around §7.1 or fabricate a clean list. L0/L1/L2 pursue only permitted evidence; actual prescribing-authority clinician and policy under O-028 determine any safe partial/exception outcome. | Record RECONCILIATION_INCOMPLETE_OR_BLOCKED, current safe reference, unresolved items, safeguards/follow-up, and compliance disposition. Test clean packet/no prescriber, expired credentials, refusal, unreachable, one unknown medication, and exception expiry. | |
| MED-E35 | A required clinical datum is stale, wrong-patient, wrong-unit, preliminary, corrected, future-dated, or temporally mismatched to the proposed decision. Requires rule, result/source, units/reference context, specimen/result/effective times, corrections, and medication proposal. | Mark ineligible for ordinary guard; L0/L1 pursue valid existing evidence; clinician determines clinical action. No negative comparison or “normal” inference from invalid data. | Hold the affected conclusion/instruction until valid evidence or approved exception. Test each defect, unit conversion ambiguity, rapid clinical change, and corrected result after decision. | |
| MED-E36 | New or corrected medication evidence arrives after terminal closure. Requires prior case/outcome/regimen, new event, received/effective time, materiality facts, and linked obligations. | Preserve the prior result and history. Exact duplicate adds provenance without new review. A genuinely new relevant fact opens linked work under approved policy; source-fact clarification is nonclinical, while unresolved clinical materiality goes to the exact authorized clinician, never L2 judgment. | Never “reopen” the old case or silently replace its evidence snapshot. Test late no-change fill, material dose correction, revoked agreement, new symptom, and attempted old-case transition. | |
| MED-E37 | Case closure or claimed GUIDE service lacks route-specific evidence, is based only on automation/L1 pursuit/infrastructure, occurs outside alignment, or uses an unapproved actor/organization. Requires closure manifest, service date/type, actor/org, alignment/tier, activity/outcome, contact cadence, and PA evidence. | Invoke X-015; review-product completion, episode closure and service qualification remain separate. Approved O-034 rules evaluate complete actual-service evidence deterministically; unresolved policy yields NOT_EVALUATED_BLOCKED. Billing/Revenue Cycle enters only an actual manual claim/payment or exception act, not routine clinical/service blessing. | Preserve clinical facts even when service qualification fails. Test clean reconciliation by approved actor, alert only, L1 chase, closed nonqualifying case, open case with qualifying service, and missing PA/cadence. | |
| MED-E38 | EHR, pharmacy, exchange, scheduling, or network outage interrupts reconciliation, order/cancel, instruction, or evidence capture. Requires affected command/release, exact regimen/case, outage source, idempotency/attempts, prior active reference, and recovery events. | Apply X-013's approved recovery; avoid duplicate execution and retain actual clinician-authored current instruction or inability to release a new one. Original L1/technical performer repairs the concrete failure; System Administrator or Software Engineering enters its actual incident; the exact authorized clinician supplies safety judgment. | No silent drop or assumed success. Resolve with matched recovery acknowledgments or authorized alternate workflow and reconcile any duplicate/late events. Test outage before/after send, unknown pharmacy state, duplicate command, partial recovery, and prolonged outage. | |
| MED-E39 | An order, recommendation, discharge direction, or medication change arrives from an outside PCP, specialist, facility, emergency department, hospital, or other clinician. Requires exact source content/event type, actor credentials/organization/scope, encounter/setting, effective status, authenticity, transmission/receipt, current regimen, and reported implementation. | Preserve it as an outside clinical event; do not force it through the GUIDE-originated §7.4 proposal route or let L1 relay it as an instruction. L0/L1 may authenticate administrative facts; the clinician authorized under O-028/O-029 determines current applicability and reconciliation. | Create independent care-plan, recipient-communication, pharmacy, access, safety, and follow-up obligations as applicable. Close intake only with source/authenticity, authorized clinical disposition, regimen effect, and linked obligation statuses. Test valid external order already effective, recommendation only, stale discharge list, wrong provider/scope, emergency change, L1 receipt, beneficiary already taking, and conflict with GUIDE proposal. | |
| MED-E40 | Allergy, intolerance, or prior adverse-reaction sources conflict, including a record stating no known allergies while the beneficiary, caregiver, pharmacy, or outside record reports a reaction. Requires product, reaction as reported, timing/severity when known, source/reporter, current regimen, proposed action, and prior allergy record. | Preserve every source; L0/L1/L2 may collect and compare but cannot confirm, dismiss, or grade the reaction. The prescribing clinician determines clinical significance and the safe medication disposition. | Hold affected ordinary instructions or orders until disposition when the conflict may matter. Resolve with source-faithful allergy/reaction record, authorized clinical conclusion, regimen effect, and communication. Test facial swelling report, vague intolerance, wrong product, old record, no caregiver, and later correction. | |
| MED-E41 | The beneficiary or authorized helper cannot accurately explain or demonstrate the intended regimen after accessible re-explanation, or teach-back reveals conflicting instructions, unsafe use, or inability to carry out the plan. Requires exact regimen/instruction, recipient, accommodations, responses, attempts, support persons, authority, and clinical concerns. | Do not document comprehension or infer incapacity from failure alone. L2 repeats approved explanation and explores chosen supports; L3/L4 addresses clinical, safety, swallowing, device, or decision-specific capacity concerns. | Withhold a comprehension-complete or self-execution claim. Resolve with successful teach-back, an authorized helper/support, a clinician-approved alternative, or an explicit unresolved risk plan. Test cross-taper, PRN maximum, hearing/language barrier, no caregiver, facility administration, and repeated failure. | |
| MED-E42 | Clinician-directed monitoring lacks an owner, timing, input, result, interpretation, communication, or response, or the required result is late, stale, invalid, or unavailable. Requires exact regimen/change, monitoring instruction, accountable collector/reviewer, due and actual times, result provenance, attempts, and beneficiary status. | Reminder/specimen/posted result is not professional review. Software/L1 tracks/retrieves; L2 supplies only actual practical support. The exact professional selected in the prescriber's monitoring plan interprets within scope; a medication change remains a prescribing act. Apply MED-E20/MED-E35 to invalid prerequisite data. | Distinguish not-required, future-due, missing/invalid input, valid-result-unreviewed and reviewed/action-returned. Future monitoring stays owned without undoing completed M14/M15; missing data needed for today's regimen makes that decision incomplete. Resolve each due obligation with reviewed action, authorized revised plan or explicit unresolved safeguards. Test lab due next month, prerequisite lab missing, unread result, wrong units, critical result and refusal. | |
| MED-E43 | The prescribed administration method is not practically usable because the beneficiary cannot swallow the dosage form, operate an inhaler or injection device, measure a liquid, open packaging, follow a taper, or safely perform another required step. Requires exact product/directions, observed or reported barrier, cognition/function, support, setting, and clinical alternatives. | L0/L1/L2 identifies and documents the barrier but does not advise crushing, splitting, substituting, changing route, or changing dose. The authorized clinician and pharmacist, within scope, determine the response. | Do not activate a reminder that assumes infeasible use. Resolve with successful training and teach-back, authorized support, a lawful regimen change, informed refusal, or an explicit unresolved safety plan. Test extended-release swallowing issue, inhaler technique, injection, liquid concentration, childproof cap, and two-strength taper. | |
| MED-E44 | The beneficiary's physical location is unknown, changes during clinical contact, or lies outside the proposed clinician's authority for assessment, triage, reconciliation, prescribing, or individualized instruction. Requires location source/time, proposed clinical act, clinician credentials/licenses/privileges, prescriptive authority, jurisdiction, and safety facts. | L0-L2 may collect facts and connect but cannot allow the licensed act through an unauthorized route. The Puerto Rico L2 operation is nonclinical and cannot become the clinical route. Immediate safety connection is not delayed for routine intake. | Hold the clinical act and route to the separate U.S. beneficiary-location-authorized clinician or emergency service. Resolve with verified location and authority or an approved alternate pathway. Test a clinical request received by the Puerto Rico navigator, a U.S. clinician not authorized for the beneficiary's location, unknown location during a safety concern, location change mid-call, and license without prescriptive authority. | |
| MED-E45 | A calendar month arrives with no assessment, request, transition, medication change, discrepancy, symptom, monitoring result, or other approved review basis, and software or staff attempts to label passive surveillance or a brief negative screen as medication reconciliation. Requires monitored sources and freshness, any participant report, actual human actor/work, candidate service purpose, and applicable trigger. | L0 may record only source coverage and no new event detected; L2 may record an attributable no-change/no-concern screen inside a real navigator contact. Neither establishes §7.1 reconciliation or creates clinical work. Do not schedule a separate medication contact solely for billing. | A prescribing-authority clinician may record complete without change only after a genuinely due reconciliation with sufficient current evidence and disposition of every material discrepancy. Test no new data/no human action, negative navigator screen, cash-purchased OTC missed by claims, routine refill, annual no-change reconciliation, and a source comparison with a material discrepancy. |
GUIDE Program Operations edge cases#
| ID | Situation | Required business handling and tests | Review |
|---|---|---|---|
| PO-E01 | A PAAF, CMS response or transfer packet contains current clinician-authored data, but needs only assembly, matching or transmission. | Software prepares/reuses the attributable product; an approved employee uses a manual portal/release capacity only where required. No new RN/physician review is created merely because the packet contains clinical fields. A genuinely missing, changed or contradictory clinical product returns to its clinical author under the owning Assessment/Medication/Coordination task and is counted once. Test clean copy, missing administrative field, invalid identifier, clinical contradiction, changed staging, expired credential, unsupported signer and accepted FHIR versus manual HDR. | |
| PO-E02 | A consent record names a caregiver but the relevant choice/authority or explanation mode is unclear. | Preserve separately the beneficiary's choice, caregiver participation, any caregiver consent permitted by the controlling GUIDE rule and decision-specific representative authority. Software may present/capture only approved modes; L2 supplies requested/required nonclinical facilitation. Missing documents stay administrative; an actual capacity judgment goes to the exact U.S. clinician; a complete uncovered legal question goes to Legal Counsel. Hold only the unsupported act under O-011/O-037/O-041/O-PA-001. Test capable-beneficiary refusal with caregiver approval, expired/limited representative authority, absent consent, approved verbal/digital documentation, late consent and withdrawal. | |
| PO-E03 | A partner contract is approved by Proxi, but CMS approval, the executed arrangement, service scope or actual service evidence is absent. | Administrative Manager's D-027 business approval proves only that exact commitment. It does not prove signing authority, CMS participation approval, clinical delivery or report/claim completion. Software keeps these facts separate; the appropriate approved employee pursues the missing source and same-lane lead recovers failure. Legal Counsel enters only for a genuine uncovered legal question. Test approved contract/pending CMS; CMS approval/no executed arrangement; both prerequisites/no service evidence; out-of-scope/out-of-date service; and a clean event needing no new manager or clinician review. | |
| PO-E04 | Program closure, a notice or monthly claim is proposed from a complete template but an actual contact, service, result, authority or child return is missing. | Software applies the exact approved evidence check and holds only the unsupported act. Billing resolves actual financial/manual-release exceptions; the original care worker finishes the missing service/return. A manager/compliance click cannot create service evidence or clinical judgment. Preserve the distinct final BAR, touchpoint and one-actual-service rules; late contact does not retroactively cure claims without O-047. Test failed outreach, unused helpline, duplicate claim, clinical product complete with future follow-up open, expired disclosure authority and mixed completed/uncompleted child actions. |
Required metrics#
- Incidence per 1,000 members/month by edge-case ID.
- Percent auto-resolved.
- Percent reaching each human level.
- Mean and percentile role-minutes per case.
- External-response time.
- Number of attempts and channels.
- False-positive and false-negative review findings.
- Linked-successor, duplicate-trigger, and erroneous terminal-reopen-attempt rates.
- Cases closed without required evidence; target zero.
Access29 semantic detecting cases#
These draft cases preserve X-019 and the local Manual14 task authorities. They are business review cases, not a new workflow engine. Current primary anchors are SRC-CMS-GUIDE-24-7-ACCESS, SRC-CMS-GUIDE-PMP-3.0 and the HHS clinical-recipient/provider-location sources.
| ID | Trigger, critical facts and failure | Permitted action, actual person and completion/fail-safe | Review |
|---|---|---|---|
| AC-E01 | A Philippine nurse is scheduled as sole daytime/on-duty third-party answer without accepted coverage basis, or mandatory sharing remains blocked. Check actual duty period, accepted care-team/Partner/third-party capacity, scope, named responder/backup and tested Tasks5/21-23 route; roster/title/phone answer alone is insufficient. | Preserve D-026 as company design. Do not activate the unsupported interval or selected third-party route. O-001/O-008/O-PA-001 requires actual accepted all-hour arrangement, accepted exact care-team capacity or separately funded accepted on-duty care-team access. No automatic PR/clinical24h shift. L1/lead and System Administrator prepare/test; actual retained approval is not invented. Independent emergency-safe help continues. Test weekday unaccepted/accepted capacity, off-duty valid/blocked sharing, shift-spanning call and no-call outage. | |
| AC-E02 | Caregiver calls from one jurisdiction about beneficiary elsewhere, then requests licensed care for themselves; the clinician is selected using caller or stored beneficiary address. Identify reporter, actual recipient/act/current physical location/time and applicable provider-location authority separately for every subject. | Software/L1 prepares source-faithful subject-specific questions; the exact appropriately authorized RN, behavioral or higher medical professional performs only the accepted scoped act. Dual-subject concerns retain separate acceptance/disposition, one shared intake. Wrong/unknown location or changed location blocks that licensed act, not safe reporting/emergency connection. Test beneficiary-only, caregiver-own, dual-subject, provider-location conflict and travel before callback. | |
| AC-E03 | Transfer, voicemail, queue, receiver answer, explicit acceptance or a callback booking is treated as completed clinical/support service; usual route unavailable or caller declines. Preserve exact concern, requested act, approved hours/response, authority, attempts, backup, accepted promise and actual result. | Paid L1 invokes configured backup without triage or safe-wait judgment. Exact clinical disposition comes from approved response policy/authorized professional; actual care-team performer furnishes support only after acceptance. Retain truthful failure/non-success when not furnished. Direct external emergency response may use0 new Proxi clinical minutes while continuing obligations remain owned. Test wrong actor, voicemail, accepted callback never made, explicit emergency, refusal, sibling concern and factual L1 callback with0 L2. | |
| AC-E04 | Information-only, declined, emergency, disconnected or multi-beneficiary third-party call is omitted from sharing; AI declined/no transcript, unavailable responder, sensitive caregiver content, wrong recipient or changed record. Preserve words/source/manual record, own-performer verification, permitted partitions and exact class/recipient/purpose/channel/restrictions. | Human-only checklist/manual note remains usable; no substitute attestation or AI clinical truth. Off-duty public sharing and accepted-daytime Proxi all-call policy remain distinct from direct care-team internal documentation. Unsupported release remains O-008/O-001/O-PA-001; affected launch fails, independent care continues. After actual approved release, verify matched usable receipt/accepted responsibility; delivery/acceptance is not follow-up. Correction/re-send requires actual applicable release evidence, with prior history preserved. Test no transcript, unavailable verifier, sensitive partition, duplicate, wrong version and late correction. | |
| AC-E05 | A current professional answer causes unnecessary repeat review, or an old answer is used to bypass a new/due protected act. Check exact author/authority, subject/location/act/question, effective instruction, unchanged facts, permission and approved reuse/re-entry basis. | Source-faithful permitted reuse can use0 new clinical minutes only after authoritative applicability. AI/L1/L2 never decide sufficiency. New symptom/conflict/subject/location/use/question, expired/conditional guidance or due required assessment/reconciliation/review opens the exact professional act directly, no L2/RN gateway. Test exact reuse, new symptom, due review, altered location and request for individualized interpretation. | |
| AC-E06 | Standing coverage is added to every active route; CG26/callback/Medication work is booked again in Access; an answered line is credited as navigator contact, furnished care or payment. Retain actual performer/act/time/fee, shared episode, receiving-service result and qualification/payment basis. | Task1 carries paid PH availability once; Tasks10-19 allocate actual active call work within it. Paid own-record work, real L2/professional event or contract fee and actual selected availability are explicit, not free Participant labor. CG26/receiving work is counted once; siblings remain independently evidenced. O-063/O-064 qualification and monthly O-009/O-047 stay distinct; PMP§3.1 rejects infrastructure-only payment. Test routine2a.m.0L2/clinical, simultaneous support/medication work, no-call availability, longer high-tail call and reuse of one actual callback/service event. |
Referral57 semantic detecting cases#
| ID | Trigger, facts and failure | Actual response, authority and detecting cases | Review |
|---|---|---|---|
| RF-E01 | Same organization has several offerings, stale/current/conflicting fields or a misleading nearby/virtual identity. Require exact programme/offering, area/population, need/recipient, hard constraints versus preferences and each fact/source/date. | Software matches corroborated identity or retains observed candidate/unknown, never force-merges or infers current capacity. L1 asks only actual missing administrative facts; person chooses, L2 only requested/required useful relationship work. Test sibling programme, known hard mismatch, material unknown, no-match versus incomplete search, stale source and undisclosed sponsor ranking. | |
| RF-E02 | General/self-referral, ordinary community referral and HCBS coordination/clinical/special-data payloads are conflated; permission/choice is treated as release. | Classify owner/data/purpose/recipient/content/channel and actual approved basis/required authorization/restrictions first. No-PHI information0release; ordinary D-007 paid assigned L2/approved-lead1/1/2 once; other class only its own actual performer/matrix. New corrected/resend/destination event needs new release. Test caregiver-owned and mixed content, narrowed/revoked sharing, no safe message, ordinary AAA referral and HCBS other-class hold with independent work continuing. | |
| RF-E03 | Preparation/release/send/receipt/intake/acceptance/active case/external first use/usefulness is called successful connection or monthly service. | Preserve four returns: actual local milestone/endpoint, real Proxi GUIDE act/content/performer, person first-use usefulness O-062, monthly O-009/O-025/O-047 qualification. Actual first furnished/use evidence—not an active case—is Proxi design under O-022, not CMS's sole definition. Test no Proxi act but external start, actual navigator service with later denial/waitlist, no-response usefulness, conflicting reports, approved applicability not yet settled, siblings and transferred pursuit with need still open. | |
| RF-E04 | Phone-only checks, status rows, repeated releases or shared contacts multiply staff minutes; a nonprofit/outside Partner is silently free. | Batch one actual13-minute search/intake exception or HCBS0/5/13 episode, count actual L2 interaction/releases once and retain longer actual work without caps. Selected portfolio priority27/35 shares actual review once. Proxi-contracted GUIDE Partner/interpreter/provider time/fee is Proxi cost; outside own programme/household acts separate. Test multiple candidates/fields, one release/initiation inside a navigator event, two genuine different sends, live shared HCBS exchange, and paid AAA assistance. | |
| RF-E05 | A caregiver's own licensed care is routed by beneficiary/caller location, or current professional answer causes a new blessing/waives due work. | Source/L1 prepares actual recipient/current location/act plus applicable provider-location; exact authorised professional performs only protected work. Dual subjects retain separate acceptance/disposition and shared intake. New symptom/conflict/location/question or genuinely due review re-enters; current scoped result only authoritatively applicable. Test NY caregiver/FL beneficiary both report-only and caregiver-own care, dual concerns, travel before act, provider-location conflict and due review. | |
| RF-E06 | Generic Participant/Program/Privacy/Quality owner selects inventory/route/signs; manager approval, a nearby agency, unsigned/expired agreement or a test send activates written assistance. | Actual D-027 business commitment, O-066 company signature and actual retained Participant party O-PA-001 are distinct. Official AAA/TitleVI mapping, actual terms/paid assistance, authorized entities/signatures/current scope and tested actual return precede reliance. Existing accepted unchanged route needs no new approval; independent direct work continues. Test direct-only/agreement/both, wrong counterpart, one signature, expired scope, current same terms, fee versus public own service and real repair job. | |
| RF-E07 | Dual eligibility/authorization implies HCBS receipt; a plan hotline is called assigned manager; asynchronous attempt/brochure/ingestion implies joint review/cooperation. | Current Medicaid, HCBS eligibility and actual receiving/effective facts separately support §6.2. Verify actual programme/manager/authority; approved genuine contact/attempt is a fact, not response/acceptance/review. General info/source ingestion can be0newL2; O-023 keeps substantive joint-review mode/finding acceptance specific. Test eligible-not-receiving, unknown/conflict, changed manager, no response, declined/limited role, complete source list without review and actual accepted review. | |
| RF-E08 | Similar labels/claims end a service, programme opinion decides clinical/payment authority, or a clean summary/plan/change flag creates mandatory L2/clinical validation. | Candidate gaps/overlap are prepared, not decided by AI. Actual programme, Billing/Revenue Cycle, Medicaid specialist or exact professional resolves only its question; no service stops by analogy. Clear current summary/delta0L2; actual request/dispute/relationship or protected implication uses original conditional shared minutes, only affected changed work reopens. Test complementary supports, partial frequency overlap, clinical equivalence, actual GUIDE payment issue, disputed owner, clear digital delta and joined-call overlapping time. |
Enhanced106 semantic detecting cases#
Use Manual19's source/date/subject facts and the linked base SOP's accepted due time, attempts and backup. Extra cadence/funding is O-052, not a new invented timer. Record actual performer/result, person-facing update, failed or pending work and next accepted action; no progress label alone supplies service/payment evidence.
| ID | Trigger and required facts | Actual response, authority and detecting cases | Review |
|---|---|---|---|
| ENH-E01 | Base and enhanced labels describe the same occurrence; require actual content, baseline duty, accepted extra result and shared time. | Keep required work available and count the event once. Enhanced credit needs distinct additional content/result; accessibility/access never need optional enrollment. Test declined package, annual fall assessment relabeled extra, one shared transition/medicine event and SV07 captions without sensory enrollment. | |
| ENH-E02 | A marketed promise has no funded performer, area capacity, contract or cost basis. | Under O-052, furnish only an accepted paid Proxi/contracted act or clearly promise coordination-only; no free Participant professional. Independent base care/preparation continues. Test unavailable OT/SLP, outside own care versus paid contractor, hidden travel/fee and signed contract without actual capacity. | |
| ENH-E03 | Clear direct preference/report is sent for routine L2 blessing. | Software captures the authenticated choice/report; L2 performs only actual requested/needed nonclinical work. Clinical question routes directly to its exact professional. Test LC04 approved match, FP supporter preference without agent appointment, MS ordinary activity and requested human clarification. | |
| ENH-E04 | AI/Companion report, pulse, silence or routing is labeled clinical monitoring, human access, completed service or payment. | Apply D-023: preserve source/subject/time and unknowns; real human return stays open. Test quiet daily input, stale/conflicting reports, caregiver-own pulse, a routed callback and chatbot-only education with no human-service credit. | |
| ENH-E05 | Beneficiary/caregiver clinical subjects or locations differ/change, or provider/act authority is unclear. | Retain separate subject/location/act/accepted professional and results, with shared intake once; no nursing title or reporter location supplies authority. Test NY caregiver/FL beneficiary report-only, caregiver-own care, dual concerns, changed location before callback and out-of-scope/modality performer. | |
| ENH-E06 | Current professional result is duplicated or reused despite new/due work. | Reuse only authoritatively applicable product; new symptom/conflict/location/question, stale instruction or due review opens the exact act. Test unchanged OT plan0new clinical work, new fall, new side effect, obsolete SLP instruction and genuinely due reassessment. | |
| ENH-E07 | Current fall/missing/choking/acute-change concern cannot reach the approved recipient. | Immediate approved local/backup route; no delayed perfect packet, autonomous emergency command, safe-wait decision or successful transfer from ringing. Preserve concern, attempts, acceptance/result and sibling work. Test failed911/clinical connection, late answer, current missing report and a nonclinical responder diagnosing severity. | |
| ENH-E08 | GPS/door/photograph/location action conflicts with choice, authority, revocation, egress or restrictions. | Hold only the affected implementation/disclosure. Actual home-safety/OT, clinical or Legal act resolves its question; software never invents liberty restrictions. Emergency-safe instructions continue. Test revoked location sharing, caregiver-only assertion, unsafe lock, changed photo destination and permitted independent help. | |
| ENH-E09 | Pain/fall/therapy/communication intervention is used outside instrument, population, language, modality or training. | Verify actual fit before protected use; missing observations do not produce a score, diagnosis or disposition. Test incomplete pain observations, camera-inferred score, self-report plus assessment, severe dementia on cited mild/moderate therapy route and casual recreation versus structured therapy. | |
| ENH-E10 | Outside referral/appointment/order/acceptance is mistaken for furnished care or useful outcome. | Preserve actual milestone and who furnished/paid; Proxi coordination is not outside diagnosis/therapy. Track truthful denied/waitlisted/declined/not-used/unknown and the next action. Test ordered-not-fitted hearing aid, SLP appointment without assessment, unaffordable device and completed Proxi pursuit with outside denial. | |
| ENH-E11 | A source, clinical result or person report arrives late, is corrected or conflicts. | Retain prior attributable history, compare actual changed facts and reopen only dependent work; no model-selected truth or duplicate event. Test corrected discharge instruction after reminder setup, late pharmacy response, beneficiary/caregiver disagreement and unchanged independent activity plan. | |
| ENH-E12 | Medication support changes an instruction, implies adherence or ignores actual administrator. | Stop the affected support for conflicting regimen or new missed-dose/crushing/timing/formulation question; O-028's exact professional returns the answer. Test facility administration, refusal, reminder silence, packaging incompatibility and an unapproved digital explanation. | |
| ENH-E13 | Planning preference becomes incapacity, legal agent or executable medical/legal form. | Preserve decision-specific authority and actual state source/form/signer; separate medical counseling/order from legal execution. L2 does not infer capacity; Legal only an uncovered question. Test failed explanation, diagnosis alone, preferred supporter, revoked document and generic POLST in an unsupported state. | |
| ENH-E14 | Nutrition/swallowing plan has generic authorship, unsafe live demonstration or AI texture/fluid target. | Keep medical, SLP, dietetic and dental contributions separate; clinician/SLP instructions control. Use safe voluntary/simulated application, preserve informed choice/comfort goals and route actual new concern. Test current choking, stale texture instruction, patient refusal, incomplete assessment and one author's result falsely closing all components. | |
| ENH-E15 | Extra follow-up is endless, burdensome, declined or booked solely for proof/claims. | State the person-specific useful reason and agreed next result/time; bundle natural contact, honor stop/defer/decline and retain baseline. Use approved base attempts/backup and truthful unresolved outcome, not contact inflation. Test no natural follow-up yet, requested stop, unhelpful home action, multiple convergent needs and contractor hourly plus duplicate fee. |
Offer selection and baseline protection detecting cases#
These concern the business offer, not new clinical/routing software. Existing service SOPs control actual urgency, due time, attempts, backup, communication and closure. Under O-052, an unsupported additional promise stays unselected/unavailable; required base work continues. Return actual scope/capacity/result and the person's choice, not a success label.
| ID | Trigger/facts | Actual response and catching cases | Review |
|---|---|---|---|
| OFF-E01 | A candidate is called included/core/standard before approved scope, person, area, time, payer and backup exist. | D-027 actual business approval and O-052 selected funded mode precede a promise; clinical authorities own protected content and O-066 any signature. Test proposed-only versus selected/accepted offer, contract without actual availability, and withdrawn capacity. | |
| OFF-E02 | Declining an extension disables an existing GUIDE need, due clinical act, caregiver support or accessible/urgent route; a summary incorrectly labels every Enhanced row optional. | Preserve D-012 base service independently. Test declined coaching followed by a caregiver question, missing-person report, acute change, transition, medication issue and SV07 accommodation. Explicit baseline-only FL02/WN02/SV07/AC02/NU03 remain available when all candidates are declined. A compound baseline/additional row does not gate the baseline. No cost-sharing/upsell can condition covered care. | |
| OFF-E03 | Referral/appointment is marketed as furnished therapy, or a paid Proxi contractor is excluded as an outside cost. | Show actual employee/contractor act versus independent outside endpoint; Proxi pays fulfillment of its promise. Test OT/SLP referral-only, contracted home worker, independent PCP treatment, group vendor fee and actual professional result still absent. | |
| OFF-E04 | One event is split into base/additional/group contacts or duplicate fees. | Attribute the actual parent work and each actual professional contribution once; retain distinct content/results. Test LC+BD practice, TR+MU+FL concern, shared assessment/field observations and already-paid baseline work relabeled extra. | |
| OFF-E05 | Offered provider lacks actual current subject/location/provider/act authority, modality, topic capability, area/hours/language or backup. | Hold only affected furnished promise; use approved backup or truthful coordination/unavailable/transfer, notify the person and preserve baseline. Test expired credential, changed patient/caregiver location, capacity loss and substitution by nonclinical Ph/PR staff. | |
| OFF-E06 | Source intervention, instrument or therapy is expanded to every stage or treated as Proxi efficacy. | Retain population, professional, method and access limits; exact qualified author controls protected use. Test mild/moderate rehabilitation evidence generalized to severe dementia, ordinary activity sold as CST, RED clinical call relabeled AI/L2 equivalent and a camera pain score. | |
| OFF-E07 | Daily Companion/whisper/pulse/silence/routed request is sold as monitoring, immediate help, actual human care or payment proof. | Apply D-023; show source/date/unknowns and actual pending human return. Test optional caregiver temperature, quiet beneficiary, request routed but not accepted and a stale Caregiver View. | |
| OFF-E08 | Current clinical product is duplicated, or a new/due/changed question is waived to keep the extra within budget. | Reuse only the unchanged authoritatively applicable product; actual new/due work uses its professional, no generic RN/L2 blessing. Test same approved routine, new side effect, yearly assessment due, failed swallowing technique and current medication question requiring prescriber scope. |
Owner-selected transport and introduction cases#
| ID | Failure to prevent | Required response and test | Review |
|---|---|---|---|
| OWN-E01 | D-031's manual sender is treated as clinical author or human release authorizer | Require the actual approved payload/recipient/purpose/permission and any required release first. Philippine L1 only transports the unchanged coordination/provider recommendation; unknown release blocks that send, not independent clinical care. | |
| OWN-E02 | D-031 is extended to Care Plan distribution, community-referral release, new patient orders, counseling, pharmacy execution or provider-agreement judgment | Preserve O-014, D-007 and each destination/clinical act. Test a mixed packet or changed recipient, patient dose question, physician disagreement and unreleased approved recommendation; obtain all applicable authorization rather than infer it from a courier choice. | |
| OWN-E03 | Family first meets its navigator only after final alignment, or a separate welcome call is forced | Under D-032, introduce the accepted primary PR navigator in useful existing initial assessment/planning work and describe pending alignment honestly. Medical-only/urgent work never waits for the meeting; actual assignment/coverage remains required. | |
| OWN-E04 | Introduction is counted again as monthly contact, assessment completion, alignment or payment | Retain actual parent work/content/time once; a greeting or logistical notice alone proves none of those results. Reassignment uses only its actual continuity work; no routine repeat after final alignment. | |
| OWN-E05 | A failed automated route creates a duplicate clinician review or free manual work | Use paid L1 for the scoped D-031 transport after required approvals, record actual send/delivery/failure and admin pursuit once. New clinical meaning uses its own professional; permitted automated transmission creates no manual sender task. | |
| OWN-E06 | Internal release policy is labeled as a universal clinical/federal requirement, or D-033/treatment purpose is treated as blanket permission | Separate clinical content, lawful basis/restrictions, D-033 approved-rule authorization and transport. Covered clean provider sends need no extra OK; any genuinely mandatory human review, D-007 ordinary navigator/lead check and other class requirements remain. Do not add a clinician to faithful sending or waive due clinical work. Apply minimum necessary only where it applies; retain narrower restrictions and never infer authority from source silence. Test approved PCP recommendation, factual treatment request, non-routine covered disclosure, changed recipient, caregiver-sensitive content and unknown contract authority. | |
| OWN-E07 | A routine envelope or D-033 courier choice is used to send an excluded/mixed packet, or the clean path still adds an extra human OK | Classify the actual content and purpose. Care Plan attachments, community referrals, patient orders/counseling, new clinical meaning and special/uncovered content keep every applicable rule; do not relabel or silently strip meaning to force the automatic class. Conversely, an accepted clean D-033 provider packet sends without another person approving it merely because it is new or resent. Actual required source review and missing authority still hold the affected act. Test mixed attachments, changed purpose/destination, mandatory restricted review, clean resend, failed automation/manual D-031 fallback and delivery without provider agreement. |
Workload, payroll and capacity detecting cases#
These detect errors in the provisional planning model, not new clinical or runtime rules. Use actual event/role/time, payout basis, cohort and schedule facts. Finance/operations corrects the estimate; existing service SOPs control actual authority, urgency, due windows, attempts and completion. A missing cost input stays unpriced; it never makes required care optional or free.
| ID | Trigger and required facts | Model response and catching cases | Review |
|---|---|---|---|
| WL-E01 | Active minutes are multiplied directly by a scheduled paid-hour rate; need actual payout unit, paid hours and productive load. | Apply D-029's $22 to scheduled PR hours, using the retained 160 hours/month and provisional 70% load. Test 246.98 active minutes →352.83 paid equivalents and $10.78 PMPM; changing utilization changes allocation, not the quoted hourly rate. | |
| WL-E02 | Training/handover/replacements are charged twice or missing; need actual hires, learner/trainer hours and whether inside the allowance. | Count learner time once inside the 30% nonservice budget or deduct it once from service capacity. Charge only actual incremental trainer/HR/overlap work to its job. Test included versus excluded 22-hour new-hire case, 20% replacement ×28 hours plus2 annual hours, live shadowing of an already-counted service and vacancy versus paid overlap. | |
| WL-E03 | One shared contact is charged separately as monitoring, planning, medication or caregiver work. | Count actual shared preparation/contact/own record once; only additional distinct work adds minutes. Test annual planning replacing a qualified contact, separate later work, duplicate copied notes and unasked topic remaining unknown. | |
| WL-E04 | Annual contact totals hide a missed window, tier change or clustered calls. | Model actual exposed tier/caregiver/residence dates and due windows; annual equivalents never authorize banking contacts. Test four calls in one low-dyad month, six clustered RCC calls, midyear tier change and a failed attempt marked complete. | |
| WL-E05 | A medical-only case gets automatic RN/L2/CMO minutes, or PR/PH is treated as clinical. | Assign actual protected act to the scoped professional and count required contributions only. Test prepared prescribing question with0 RN gateway, caregiver-own subject in another state, a current applicable clinical result and a new/due review that cannot be waived. | |
| WL-E06 | The same clinical issue is counted in assessment, transition, medicine, plan and 24/7. | Use one owning event and separate entry channel; retain each actual professional contribution. Test post-discharge medication discrepancy entering through24/7, genuinely new plan question, nursing-only versus medical-only versus joint case and late correction reopening only affected work. | |
| WL-E07 | Initial-minus-annual difference is treated as all first-year clinical work. | Count initial and actual annual events inside the selected horizon; alignment start is staging date, not final BAR notice. Test f0/.5/1 cohort cases, annual started late with the earlier60-day/day425 deadline, failed final alignment acquisition cost and a partial first payment month. | |
| WL-E08 | RCC caregiver unknown becomes absent, multiple caregivers disappear, or group work is multiplied by every topic. | Keep unknown caregiver exposure explicit and actual recipients/attendance. Allocate one facilitator session once, not hourly work plus the same fee. Test RCC caregiver present, two independently served caregivers, declined course/support and an unasked domain mislabeled no change. | |
| WL-E09 | Every cost pool is forced to one divisor, or distinct Participant blocks are collapsed. | Use each pool's actual covered cohort and multiplicity plus variable/step work. Test one5,000-life PH roster with ten500-life programme blocks, one truly shared300-hour block, unshared language coverage and per-claim work at larger scale. | |
| WL-E10 | Low/high PH rows do not follow shrinkage/reserve inputs or use an unexplained extra seat. | Recompute clock minutes, contracted paid hours, distinct shrinkage/reserve and lead allocation. Test6.677/7.419/8.275 FTE, zero reserve, leap-year clock, PH2,080 versus PR1,920 annual paid-hour convention and an explicitly selected second seat. | |
| WL-E11 | Low average call occupancy is treated as proof of24/7 answerability. | Validate interval arrivals, concurrency, noninterruptible work and actual backup. Only truly absorbable admin work stays inside paid coverage; overflow/extra capacity is paid. Test outbound call during a new incoming call, two callers, transfer hold, language mismatch and outage. | |
| WL-E12 | Unknown rates/fees/availability become0 or delivered-hour and roster-hour quotes are mixed. | Preserve unknowns and actual minimum/retainer/scheduled/active units. Test a null clinical quote, contracted receiving availability, required part-time physician director for a nonphysician dementia-proficient clinician and source-owned outside care versus paid Proxi fulfillment. | |
| WL-E13 | Field or enhanced tasks borrow PR pricing, annual clinical minutes or count every label as an appointment. | Use D-028's actual onsite worker/fee/travel and one shared clinical event; O-052 adds only activated incremental occurrences/capacity. Test low-tier remote visit, required/elected paid visit, RCC applicability unknown, failed connection and106 labels without106 extra visits. |