Low-burden monthly service plan

Status: COMPLETE WORKING BUSINESS DESIGN; not yet approved for field use; executed Participation Agreement and owner/compliance/clinical review still required
Date: 2026-07-14
Scope: How Proxi schedules and combines the eight in-scope GUIDE services without manufacturing contacts or unnecessary clinical work. Respite remains excluded.

Decision in plain language#

Proxi should schedule to the beneficiary's required human contact cadence, not to eight separate service calendars and not to a monthly medication-reconciliation or care-plan-revision quota.

The operating rule is:

One person-facing interaction may furnish several applicable GUIDE services. One service should not generate several person-facing interactions.

For every monthly-contact tier, the required substantive navigator contact is the ordinary monthly service anchor. The navigator opens with a genuine opportunity to raise a change, concern, or chosen priority, then uses only the plan-fit, medication-use/access, open-action, caregiver, or no-caregiver prompts relevant to the selected service and current evidence. The contact spends its time on the one or two matters that are actually useful that day; it does not imply that every domain was reviewed.

For low-complexity dyad and RCC off-contact months, Proxi may bill only when an actual patient-specific non-contact GUIDE service is furnished while the contact cadence remains current. If no real service is due, Proxi should not contact the family or create clinical work merely to fill the billing month. That month has no DCMP claim.

A no-service month does not immediately lose the beneficiary. The current CMS claims-based unalignment condition is eight consecutive months without either a DCMP or GUIDE Respite Services claim. Normal quarterly or bimonthly contacts keep a compliant program well inside that interval. This does not authorize skipping the applicable contact cadence.

Public basis: CMS GUIDE Payment Methodology Paper v3.0 §3.1 ↗ and GUIDE RFA Appendix B §§2-8 ↗. CMS specifies the contact cadence and the requirement for a furnished service, but it does not specify contact minutes or require every service domain every month.

Value comes before the billing label#

Cadence determines when contact is due. A real GUIDE service determines what the contact is for. The person-facing result determines when the contact is finished. Billing classification happens afterward. Proxi must never choose a service label or duration and then invent content to support it.

Before a planned human contact, staff must be able to say:

Contact [beneficiary or permitted caregiver] because [required cadence, their request, a new event, or a named open action] requires a human conversation now. Proxi will provide [specific service] so the person receives [specific useful result]. Planned direct time is [8, 15, or 25 minutes], and no recent qualifying interaction or existing evidence already satisfies this purpose.

“Monthly check-in,” “touch base,” “engagement,” “see how they are doing,” “review everything again,” and “fill the billing month” are not sufficient reasons. If staff cannot name the service and person-facing result, they must cancel or redesign an optional contact. When the tier-required contact itself is due, the service is a brief person-led ongoing-monitoring and support interaction—not a ceremonial call—and it must produce at least one person-specific ongoing-support outcome.

A contact has person value when the approved human navigator provides a genuine two-way opportunity to raise, choose, or decline topics and completes at least one person-specific result. The result may answer a question, advance a due action, furnish selected support, or obtain attributable confirmation that a relevant current goal or action still fits and no additional help is wanted. The contact closes with a usable next step or help route. Duration, script completion, and the number of GUIDE domains mentioned do not establish value.

What Proxi actually provides and why it contacts the person#

Provider pursuit, record retrieval, claims review, referral-status checking, care-plan comparison, and medication surveillance normally do not justify contacting the beneficiary or caregiver. Contact them only when their facts, choice, understanding, participation, or action is needed—or when Proxi has a meaningful result, barrier, warning, or support service to return.

The monthly selection order#

For each beneficiary-month, use the first applicable item below. Do not defer needed work or split one natural episode across months merely to create additional claims.

1. Use a tier-required navigator contact that is due. Bundle every applicable person-facing topic into that one interaction.
2. Reuse a naturally occurring qualifying interaction. A substantive inbound navigator call may replace the planned outbound contact when it independently satisfies the same actor, modality, participant, purpose, and documentation requirements.
3. Perform a real event-driven service. Transition, medication, clinical coordination, referral, safety, caregiver, or other work follows the event when it occurs.
4. Complete an open care-plan promise or service action. Follow through on a result, barrier, referral, provider response, schedule support, or caregiver action that is actually due.
5. Furnish a beneficiary- or caregiver-selected service. Respect their choice of topic, timing, channel, and participation.
6. Perform planned patient-specific maintenance only when genuinely due. An annual assessment, requested medication review, triggered care-plan review, or other legitimate recurring work may be scheduled; a calendar month by itself is not a clinical trigger.
7. If none applies, do not manufacture a service. Record no service and release no DCMP claim for that month.

Tier-aware contact plan#

An actual caregiver-only contact may satisfy the public beneficiary-and/or-caregiver contact route when the caregiver is permitted to participate and the contact is substantive. It does not give the caregiver authority to replace beneficiary leadership in care-plan choices.

When a required contact does not happen normally#

• Unreachable: Try across the applicable window using the person's preferred channel and one permitted alternate, spread across the window rather than clustered at the end. The provisional default is three attempts across two channels pending O-055. Record every attempt as an attempt; attempts are paid labor but never contact or service credit. If the touchpoint becomes overdue, another service does not cure the cadence problem and the DCMP remains blocked until the controlling rule is satisfied. O-047 owns any late-billing question.
• Declined or stop requested: A one-time “not today,” a channel/topic preference, a standing cadence refusal, and a request to leave GUIDE are different. Follow the preference/refusal procedure below and O-050; do not turn refusal into unreachability or manufacture another service.
• Interrupted: If the named substantive purpose and person-specific result were completed before the interruption, the record may support the window and must state what was not reached. If substance did not occur, schedule completion. A same-day continuation is one contact. A safety interruption follows the clinical/emergency route and is not absorbed into navigator minutes.
• Second individual-tier contact with nothing open: The contact still occurs because it is a cadence requirement. Give the brief person-led continuity service described in Monitoring, do not repeat Contact A, and do not invent a deeper agenda.
• Inbound or overnight event: Evaluate the substantive navigator portion against the same actor, modality, participant, and content requirements. A first-answer intake does not qualify. If the completed episode qualifies for the current window, cancel the redundant outbound contact under X-017. After clinical or emergency handling, add a navigator follow-up only for a remaining nonclinical need or promised action—not to make the person retell the event.

The 8 / 15 / 25-minute service bands#

Proxi does not choose a duration and then fill it. Proxi identifies the service, necessary person participation, and expected result first. The 8 / 15 / 25-minute figures are capacity bands assigned afterward. The interaction ends when the useful result is achieved or a truthful handoff and next step are established.

An eight-minute contact does not claim that every detailed monitoring card was completed. Begin with one open invitation for change or concern, then address the person-selected or actually due focus. A domain not covered remains not asked, not “no change.” A stable negative result can be legitimate person-led ongoing monitoring, but it ordinarily supports one substantive navigator contact—not separate claims that medication reconciliation, whole-plan review, caregiver education, and coordination all occurred.

“Complex” describes the beneficiary's nonclinical logistics, communication, accessibility, or number of linked actions. It never expands Puerto Rico L2 clinical authority. If a clinical or safety issue appears, the navigator gathers only the permitted source-faithful handoff facts, transfers to the separate beneficiary-location-authorized U.S. clinical or emergency route, and counts that work separately. The ordinary agenda resumes only when safe, useful, and wanted.

A focused second individual-tier contact may be approximately 5 / 10 / 15 minutes. It follows one named action, barrier, skill, safeguard, or goal and never repeats Contact A's complete screen. These ranges remain provisional scheduling assumptions under O-039, not minimums, maximums, billable units, or required talk time. The contact may be shorter when the substantive purpose is completed or longer/split when the person prefers and an actual need warrants it.

Preparation, documentation, and real follow-through are Proxi labor but should not extend the beneficiary-facing conversation. The existing 20/25-minute navigator staffing envelopes remain provisional until O-039 reconciles direct-interaction time with preparation, documentation, retries, and observed field data.

Optional six-focus depth menu for monthly-contact tiers#

This menu may shape an already-required contact after the reason and person-facing result are chosen. It never creates the reason for contact. The person may decline the suggested focus; it should be skipped when irrelevant, recently completed, or less useful than another chosen need. A “medication month” never justifies a deeper medication interview when no medication need exists.

Every contact begins with an open invitation for a change, concern, or chosen priority. Ask the plan-fit, medication-use/access, open-action, caregiver, or no-caregiver questions only when they are relevant to the selected service, current evidence, an open obligation, or the person's concern. Credit only the work that actually occurred; an unasked domain remains unknown for that contact.

Low-burden service menu#

The classification below is a public-source operating recommendation, not a final claim determination under the missing executed Participation Agreement.

Not an acceptable monthly service by itself#

• AI-only or software-only surveillance, chart scanning, list comparison, summary, or “no change detected” result;
• a reminder, calendar booking, scheduling conversation, voicemail, SMS, or unanswered attempt;
• passive 24/7 availability, a passive education library, or an unused support-group offer;
• an administrative task creation, status display, directory refresh, or infrastructure-maintenance activity;
• a Philippine first-answer call that only captures a callback request or attempts a transfer;
• repeating an unchanged medication list or rewriting a care plan solely to create documentation;
• a generic check-in with no substantive ongoing-support purpose; or
• any service performed only because billing staff found an empty month.

Medication: what “nothing changed” means#

CMS RFA Appendix B §7.1 requires a clinician with prescribing authority to review and reconcile medications during the initial comprehensive assessment, during future assessments, and periodically when requested by the care team, beneficiary, or caregiver, as appropriate. It does not require monthly reconciliation.

A real no-change reconciliation exists when the prescribing-authority clinician reviewed sufficiently current evidence, disposed of every material discrepancy, and explicitly concluded that the intended regimen remains unchanged. A no-delta software comparison or a two-minute negative navigator screen is not that event.

Stable-month medication questions are limited to:

1. Has anyone started, stopped, or changed any prescription, nonprescription product, vitamin, or supplement?
2. Is anything being taken differently, skipped, refused, or used only sometimes?
3. Is anything hard to obtain, organize, swallow, administer, understand, or afford?
4. Is there any new fall, confusion, sleepiness, reaction, or other medication concern?

If the answers are explicitly negative and no material source signal exists, record the negative screen, create no separate medication contact, and use no U.S. clinician time. If an assessment, request, transition, discrepancy, self-change, symptom, monitoring result, or medication question exists, route only the actual issue to the appropriately authorized U.S. clinician.

Care plan: review is not revision#

The ongoing contact includes a brief care-plan fit check: does the relevant plan still fit, does the person want a change, and is anything important missing? A beneficiary-confirmed “still fits” is useful plan-maintenance evidence inside that contact. It does not require a new plan, cosmetic wording change, or separate clinical blessing.

A full whole-plan reviewed-no-change outcome is different. It requires current assessment/review inputs, beneficiary-led confirmation, review of every applicable plan section, disposition of material differences, and scoped professional review only where renewed professional judgment is actually required. The existing annual/triggered planning estimate is 15 / 25 / 45 Puerto Rico navigator minutes. It should not be scheduled monthly.

Software may compare the current plan with available records and prepare possible differences. “No fields changed,” “no new claim appeared,” or “the AI found no mismatch” does not prove that the plan still fits or that the beneficiary confirmed it.

Workforce assignment#

Member preference and burden protections#

• Use one primary navigator to coordinate person-facing work.
• Record preferred channel, time, participants, safe-message limits, desired call length, and topics the person does not want repeated.
• Bring forward reliable stable facts and ask what changed instead of repeating the full assessment.
• Offer an agenda preview when desired and allow removal of nonmandatory topics.
• Bundle medication, care-plan, referral, caregiver, and practical follow-up into one interaction.
• Use a substantive qualifying inbound interaction instead of making the person repeat the same conversation later.
• Reoffer an optional service after a decline only when the person asks, the need changes, the service changes materially, or a defined reassessment calls for a new offer.
• Explain required contact implications neutrally. Never pressure a beneficiary or caregiver based on Proxi's billing interest.
• Treat explicit refusal as a choice, not as unreachability. Distinguish a one-time reschedule, a channel/topic preference, a standing refusal of required-cadence contact, and a request to leave GUIDE. Honor a reschedule or preference immediately. For a standing refusal, record the authenticated refusal and reason; offer the least-burden compliant alternatives—a different navigator, modality, shorter stable contact, different timing, or permitted caregiver route; explain the cadence and possible program consequence neutrally; continue only contact the person agrees to; and send the unresolved compliance/billing question to O-050. Never fabricate a contact, keep calling after a standing stop request, or turn refusal into a welfare concern without independent evidence. A request to leave GUIDE follows the program withdrawal/unalignment work. An actual safety signal still follows the approved safety route.
• Extra nonclinical contacts require beneficiary/caregiver agreement. Extra clinical frequency requires an authorized clinical basis.
• Do not delay urgent, clinically needed, time-sensitive, or beneficiary-requested work to move it into another billing month.
• Do not fragment one natural episode into several actions merely to create several monthly service records.

Burden warning signs#

The primary navigator or operations owner should review the schedule when:

• multiple Proxi roles separately contact the same person about matters that could have been bundled;
• the person says, “You already asked me this”;
• contacts repeatedly produce no new information, requested support, action, or meaningful confirmation;
• optional education or support is repeatedly offered after a clear decline;
• repeated no-shows, shortened calls, rescheduling, channel changes, or requests for fewer calls appear;
• contact time repeatedly exceeds the person's preferred length without a named reason;
• the caregiver reports that GUIDE itself is adding burden;
• staff cite an empty billing month as the reason for outreach; or
• the second required individual-tier contact repeats the first contact's complete screen instead of addressing one useful focus.

Illustrative months#

Decisions still requiring owner approval#

• O-009: exact evidence required for each non-contact monthly service, including deterministic execution, substantive 24/7 events, and no-change outcomes.
• O-010: whole-plan reviewed-no-change evidence and the boundary between a brief contact-level fit check and a full plan review.
• O-028: exact prescribing-authority and medication-review roles, sufficient current sources, and no-change/incomplete reconciliation evidence.
• O-034: medication-service evidence for billing treatment.
• O-039: direct-interaction and total active-human minute ranges after field observation.
• O-047: whether a late required touchpoint ever permits retroactive billing for an earlier otherwise-supported month.
• O-050: what a sustained refusal of required-cadence contact means for tier compliance, DCMP claims, and alignment; which lower-burden alternatives must be offered; whether a permitted caregiver route can satisfy cadence; and what evidence is required.
• O-055: the reasonable-attempt standard for required contacts, including the provisional three-attempts/two-channels default used above.
• O-PA-001: reconciliation against the executed Participation Agreement and contractual Appendix D.

Until those decisions are approved, the conservative rule is: use the required navigator contact when due, prefer actual need-driven work, distinguish no-change outcomes from no work, and do not manufacture a service.

The business-design unit is complete. The open items above are activation and field-validation controls, not missing sections of the service schedule.