Medication management and reconciliation

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

Public service anchor: CMS GUIDE RFA Appendix B §§7.1-7.5 ↗. Transition medication work also appears in Appendix B §5.4. The Proxi column identifies candidate automation, not functionality already deployed. The acquired Participant's current executed agreement still needs to be checked before operations are finalized.

GUIDE minimum, customer value and clinical judgment#

The public minimum is prescribing-authority review at the required assessment and requested review occasions (§7.1); conditional prescribing/deprescribing work by the named Participant professionals (§§7.2–7.3); recommendation sharing and relevant-provider agreement before a GUIDE-recommended medication change (§7.4); navigator information on schedule supports (§7.5); and medication support during applicable transitions (§5.4). There is no public monthly reconciliation or fixed-minute requirement. SRC-CMS-GUIDE-MEDICATION records this targeted interpretation.

The following operating detail is Proxi design. It makes the minimum useful to the person without turning every logistics task into a clinical encounter.

Beneficiary/caregiver reports and choices are not Proxi-paid labor. Outside pharmacy, payer, facility and clinician actions are recorded separately from Proxi work. A prepared clinical question does not require a Puerto Rico navigator stop. Clinical, explanation, pharmacy, possession, use and monitoring milestones are separate; the completion table below controls.

Medical SOP purpose and clinical boundary#

This SOP defines how Proxi obtains the best available medication history, preserves each source's claim, compares discrepancies, obtains prescribing-authority reconciliation, coordinates any medication change, communicates an authorized regimen, confirms understanding and practical implementation, and monitors the result.

Medication reconciliation is not selection of the newest or most authoritative-looking list. It is the prescribing-authority clinician's comparison of the best available medication history with current orders, treatment plans, transition information, reported use, supply evidence, allergies and reactions, symptoms, and unresolved questions, followed by an explicit determination of the intended regimen and disposition of every material discrepancy.

The following remain separate even after reconciliation:

• Current operative clinical instruction: the instruction the authorized clinician identifies as currently applicable, including any limits or uncertainty.
• Clinician-recommended change: a proposed new regimen and its required agreement/order/choice gates; it does not become active merely because the clinical review is complete.
• Order or prescription: the legally valid request issued by an authorized prescriber.
• Transmission and pharmacy response: whether the order or cancellation reached the pharmacy and how the pharmacy responded.
• Dispense or handoff: what the pharmacy or facility actually supplied or handed over.
• Possession: what appears to be present and accessible to the beneficiary, caregiver, or facility.
• Reported use: what the beneficiary or caregiver says is being used, stopped, skipped, changed, or refused.
• Administration: a documented dose actually administered in a facility or by another person.
• Unresolved source assertion: a material fact that remains missing, ambiguous, stale, or conflicted.

Reconciliation does not prove that the beneficiary obtained, understood, or implemented the intended regimen. Likewise, a claim does not prove dispensing, a dispense event does not prove possession, and possession does not prove use.

Order does not prove transmission; transmission does not prove pharmacy acceptance; acceptance does not prove dispensing; a claim does not prove handoff; dispensing does not prove possession; possession does not prove use; and reported use does not prove administration.

CMS RFA §§7.1-7.5 establish the public GUIDE obligations. The detailed interview dataset, discrepancy method, teach-back, monitoring plan, and closure criteria below are Proxi clinical operating design informed by AHRQ MATCH and RED medication-safety guidance; they are not additional CMS requirements.

Monthly monitoring is not monthly reconciliation#

CMS RFA §7.1 requires prescribing-authority review and reconciliation at the comprehensive initial assessment, at future assessments, and periodically when requested by the care team, beneficiary, or caregiver, as appropriate. It does not require monthly reconciliation.

Keep these activities and outcomes separate:

A real no-change reconciliation exists only when the prescribing-authority clinician reviews sufficiently current evidence, disposes every material discrepancy, and explicitly concludes that the intended regimen remains unchanged. “No new claim,” “no source delta,” and “no change reported” do not mean the same thing and do not become reconciliation. Do not create a separate medication contact or clinician review solely because the billing month is otherwise empty.

Proxi supplies or contracts the assigned labor under the validated Participant and Partner Organization arrangement. The enrolled GUIDE Participant retains nondelegable responsibility for the Section 7 service, care-team supervision, clinical quality, disclosure controls, and supporting evidence. External prescribers, pharmacies, facilities, and emergency services retain the clinical, dispensing, administration, or emergency acts only they can furnish.

Authority and role assignment#

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

Cross-pillar preparation, no-repeat handoffs, owner acceptance, and shared labor follow 25_GUIDE_Eight_Pillar_Service_Integration.md. A source-separated prepared medication question routes directly to the beneficiary-location-authorized prescribing or other qualified clinical owner; Puerto Rico L2 is never the clinical gateway.

Triggers and required clinical owner#

Minimum medication-history dataset#

For every prescription medication, OTC product, vitamin, supplement, herbal or natural treatment, sample, compounded product, and other substance, obtain as much of the following as the sources support:

• verbatim product name and any source code or image;
• ingredient or product identity only to the specificity actually supported;
• strength or concentration, dosage form, route, amount per dose, frequency, times, duration, and effective dates;
• PRN indication, conditions, interval, and maximum when prescribed or documented;
• taper, cross-titration, alternating-day, multi-strength, conditional-hold, split-tablet, device, or other complex directions;
• indication or purpose as documented by a clinician and as understood by the beneficiary, without converting a lay report into a diagnosis;
• prescribing or recommending clinician, practice, and treatment relationship;
• order, prescription, stop, cancel, dispense, reversal, administration, and transition sources with event and receipt dates;
• whether the item is reportedly possessed, placed in packaging or a pill organizer, used, missed, refused, self-changed, stopped, or administered, including last known dose when clinically relevant;
• pharmacy, facility, mail-order, sample, cash, caregiver, or other supply route and available quantity or days supply;
• reported benefit, problem, symptom, fall, confusion, sedation, swallowing or device difficulty, cost, coverage, shortage, transport, packaging, or other access barrier;
• who organizes, reminds, assists, or administers the medication and what schedule support is currently used; and
• source, reporter, observation time, record time, confidence limitation, correction, and unresolved conflict.

Medication allergies, intolerances, and prior adverse reactions are collected as a separate clinical record. Capture the product, reaction as reported, timing and severity when known, reporter, and source. A vague report is not automatically promoted to a confirmed allergy, and a contradictory “no known allergies” record does not erase it.

No source wins by default. EHR lists, pharmacy claims, bottles, discharge paperwork, facility records, beneficiary reports, and caregiver reports each establish only what that source can prove.

Universal medication-safety bypass#

When any person reports a possible overdose, wrong medication or dose, acute symptom, fall, confusion, sedation, allergic-type reaction, missed critical therapy, self-change, administration error, or request for urgent medication advice:

1. The first human responder confirms identity, callback number, current physical location, medication or substance involved, what was taken or omitted if known, last known dose when safely obtainable, symptoms or event, onset and timing, and actions already taken.
2. The responder records the report verbatim without assigning causality, severity, urgency, or treatment.
3. Immediate danger invokes the approved emergency pathway without delaying for a complete history. Otherwise, connect the beneficiary or caregiver to the beneficiary-location-authorized RN, prescribing clinician, or other approved clinical professional.
4. L1/L2 does not advise starting, stopping, holding, repeating, crushing, splitting, substituting, or changing medication unless relaying an exact instruction previously authorized for that exact situation.
5. Failed connection remains an active escalation. Record who accepted the handoff, the clinical disposition and instructions, emergency action, unsuccessful attempts, and the resulting reconciliation, communication, or monitoring work.
6. Completing a safety handoff does not itself complete medication reconciliation or prove the medication caused the event.

Detailed medication review and reconciliation procedure#

1. Confirm identity, location, participation, and authority. Verify the beneficiary, current physical location and care setting, respondent identity, beneficiary participation, caregiver or representative role when relevant, preferred language, accessibility needs, and the proposed clinician's authority.
2. Build the source-faithful reported-use history before navigator or clinician time. Software presents the source-separated candidate list through an accessible structured text, voice, photo, or assisted intake and asks the beneficiary/caregiver to confirm, correct, or supply what is actually used, how each item is used, what changed, what is missed or refused, what problems or barriers exist, and who assists. Ask explicitly about OTC products, supplements, natural treatments, samples, inhalers, injections, eye or ear products, creams, patches, liquids, and PRN items. L1 pursues disconnected records or helps with the administrative intake. L2 conducts the human relationship-based interview only when the required service or person request calls for it, or accessibility, ambiguity, conflict, distress, disagreement, or relationship context remains.
3. Confirm allergies and previous reactions. Collect the separate allergy/reaction history and preserve disagreements for clinical review.
4. Collect independent sources. Obtain available EHR lists and orders, prior reconciliation, PCP and specialist records, pharmacy and claims events, bottles or photographs, facility MAR or administration records, discharge instructions, home health records, and beneficiary/caregiver reports. Record what is still missing.
5. Normalize identity conservatively. L0 may perform exact approved terminology mapping. Strength, concentration, form, route, release characteristics, salt, compound, combination product, and ambiguous text remain distinct unless the evidence supports the match. Therapeutic equivalence is never an automated identity decision.
6. Compare medication by medication. Identify exact matches and differences involving omission, addition, ingredient, strength, concentration, form, route, dose, frequency, timing, PRN instructions, hold or stop instructions, intended overlap, substitution, indication, prescriber, supply, administration, and reported use. Distinguish documented intentional differences from unexplained differences.
7. Prepare the clinician packet. Present the best available history, every source assertion, allergy/reaction record, literal discrepancies, reported symptoms and actual use, access and administration barriers, transition context, relevant existing clinical information, pending questions, and original source documents. AI may summarize but cannot remove contradictions or declare the list clean.
8. Perform prescribing-authority reconciliation. The clinician evaluates the complete packet and determines, for every medication or substance, the current applicable instruction and any recommended continue, start, stop, hold, change, or conditional-use disposition. Record current instructions separately from a proposed change awaiting agreement, order or person choice. The clinician records dose, route, frequency, indication or purpose, effective timing, clinically important conditions, rationale for material differences, and required monitoring.
9. Record separate clinical and real-world facts. The clinician separately records the intended regimen, beneficiary-reported use, apparent supply or possession, administration evidence, and remaining uncertainty. The clinical conclusion does not erase contradictory evidence.
10. Classify the reconciliation result. The clinician records complete without changes, complete with changes, or incomplete because material information remains unavailable or disputed. A no-change conclusion requires disposition of every material discrepancy. For an incomplete result, the clinician identifies the current instruction that remains in effect or states that no safe new instruction can be released, lists unresolved questions, assigns follow-up, and defines safeguards.
11. Route every proposed change correctly. Distinguish a GUIDE-originated proposal, an authenticated outside order already issued or effective, an outside recommendation without an order, and a beneficiary self-change. Apply the procedures below.
12. Issue and execute authorized orders. After the required clinical authority and provider agreement are authenticated, the authorized prescriber may create the lawful order or cancellation under clinical policy. Before a non-emergency change is implemented or communicated as active instructions, explain it and record the beneficiary's or authorized representative's choice. Track the recommendation, agreement, order, transmission, pharmacy response, dispensing or handoff, possession, choice, and reported implementation separately.
13. Synchronize required destinations. Update the EHR medication record, care plan, pharmacy, beneficiary instructions, authorized caregiver or representative, facility administration information, schedule support, and applicable clinicians as required. One successful destination does not prove another.
14. Communicate and confirm understanding. Provide accessible clinician-approved instructions and use teach-back. Do not represent a proposal as an active regimen.
15. Implement practical supports. After the regimen is clinically authorized and understood, L2 helps address access, packaging, reminders, pill organizers, applications, caregiver/facility support, and other chosen aids without simplifying conditional clinical directions.
16. Monitor and follow through. Confirm whether the beneficiary obtained and reportedly implemented or refused the regimen, whether symptoms or barriers appeared, whether monitoring occurred, and whether every result reached the responsible clinician. New material information creates new review work rather than silently changing the prior record.

Task-level medical operating cards — M01-M16#

These cards make the review-and-reconciliation episode executable. Minute ranges are operating estimates, not CMS minimums, clinical deadlines, or reasons to create work. Count one human episode once even when it satisfies several cards. In particular, M03-M06 share one reported-use intake episode, M07-M09 may share one source-pursuit episode, and M14-M15 share one prescribing-clinician reconciliation episode. Clean software preparation creates 0 human minutes. The ranges below describe low / ordinary / complex cases and must be replaced by observed operating data.

M01. Identify when medication review is due#

When. Evaluate every initial Assessment, future Assessment, authenticated care-team/beneficiary/caregiver request, transition, outside medication event, discrepancy, self-change/refusal, symptom/safety report, or returned monitoring result. A new month, an empty billing month, background surveillance, or no source delta is not by itself a reconciliation occasion.

Required facts and provenance. Event type and source; event/receipt time; current Assessment or transition identity; exact requester and request; medication issue as stated; duplicate/prior review link; and any immediate-safety cue. A claim, alert, or model difference is a candidate event only.

Procedure. Software matches the event to an approved occasion, deduplicates it against open medication work, and records one of: full §7.1 review due; bounded medication question due; transition review due; safety route first; administrative verification needed; no qualifying review occasion; or unresolved occasion under O-028. Independent urgent work proceeds without waiting for occasion classification.

Automation and human work. Software performs the clean determination. L1 verifies an external request, transition, or duplicate fact only when disconnected. L2 enters only when the person's intended request or relationship context is unclear. The prescribing clinician does not review a clean no-trigger event.

Estimated human minutes. Clean: 0. L1 exception: 3 / 7 / 12. L2 relationship clarification: 0 / 5 / 10. Clinical: 0 here; later M14 time applies only when a supported occasion requires reconciliation.

Completion evidence. Exact occasion and scope, source, duplicate disposition, safety precedence, receiving task, and why no review was opened when applicable. Detection, alerting, or task creation alone is not a medication review.

M02. Confirm beneficiary, setting, participants, and clinical authority#

When. Before collecting or disclosing person-specific medication information and again before any licensed act when the beneficiary's location, setting, participant, or clinician authority changed.

Required facts and provenance. Beneficiary match; current physical location and care setting; transition status; respondent identity; beneficiary participation; caregiver/representative basis for this interaction; permitted disclosure scope; preferred language and accommodations; proposed clinician identity, organization, license, jurisdiction, and requested act.

Procedure. Software validates supported identity, participation, location, and roster facts. L1 corrects a missing identifier, current location, endpoint, or credential record. L2 clarifies a beneficiary/caregiver participation or communication issue. If the exact clinical performer lacks beneficiary-location authority, hold only the licensed act and select the appropriate authorized route; do not delay an emergency connection.

Automation and human work. Clean validation is software. No privacy reviewer or clinician blesses a fully supported routine case. A genuine uncovered authority question remains held under the approved legal/clinical escalation rather than being guessed.

Estimated human minutes. Clean: 0. L1 factual correction: 2 / 5 / 10. L2 participation/accessibility clarification: 0 / 5 / 12. Clinical: 0 unless a separate clinical act begins.

Completion evidence. Matched person, location/as-of time, setting, participants, permission scope, accommodations, and exact authorized clinician for the act. A chart header, caregiver label, clinician title, or roster presence alone is insufficient.

M03. Obtain the prescription-medication report#

When. During the source-faithful intake for an applicable M01 occasion. Do not repeat an already current attributable answer unless a new event, correction, conflict, or clinically required question makes it necessary.

Required facts and provenance. Source-separated candidate prescription list; beneficiary/caregiver reporter; current use as reported; unknown products; products not on the candidate list; label/photo/source identifiers; and accessibility needs.

Procedure. Present each candidate as a source assertion, ask what prescription medications are actually used, add omitted items, and record uncertain or declined answers without converting them to no use. Preserve intended order, possession, reported use, and administration as separate facts.

Automation and human work. Accessible software intake is the clean path. L1 assists with an administrative intake or photo/record transfer. L2 conducts a relationship-based interview only when required/requested or when accessibility, ambiguity, conflict, distress, disagreement, or relationship context remains.

Estimated human minutes. Count M03-M06 once as one intake: software-only 0 Proxi human minutes; L1 assisted intake 5 / 12 / 25; L2 human interview 8 / 18 / 35. Do not add those bands separately for each card.

Completion evidence. Reporter, time, each reported prescription item or explicit uncertainty/decline, source links, corrections, and unasked/unresolved items. A copied EHR list or claim history is not the person's current-use report.

M04. Obtain OTC, supplement, natural-treatment, and other-substance reports#

When. In the same applicable intake as M03 and whenever a new product or correction is reported.

Required facts and provenance. Verbatim product/ingredient when supported; label/photo; strength/form/route; reported purpose and use; source/reporter/time; and uncertainty. Ask explicitly about vitamins, supplements, herbs, natural products, samples, inhalers, injections, eye/ear products, creams, patches, liquids, PRN products, and other substances.

Procedure. Use a complete accessible prompt set without presuming the product is harmless or clinically meaningful. Record "none reported" only when the relevant question was actually asked and answered. Route unknown identity, interaction, symptom, or safety questions without interpreting them.

Automation and human work. Same shared M03-M06 intake. Software captures and separates facts; L1/L2 enter only under the shared exception. Product or clinical significance is not decided by intake staff.

Estimated human minutes. Included in the single M03-M06 intake band; typical component 2-5 minutes, not additional billed labor.

Completion evidence. Complete prompt coverage, attributable response, each product assertion, unknowns, declines, and any exact clinical question. A blank field or absence from claims/EHR is not "none."

M05. Record how each item is actually used#

When. For every reported item in the applicable intake and after a new use, nonuse, refusal, self-change, administration, or possession fact appears.

Required facts and provenance. Reported amount, route, timing, frequency, PRN conditions, missed/extra doses, recent start/stop/change, refusal, last known dose when relevant, who organizes/assists/administers, and reporter/time. Keep order, supply, possession, reported use, and administration distinct.

Procedure. Ask source-faithful questions and retain the person's words. Do not label the report adherence/nonadherence, safe/unsafe, correct/incorrect, or authorized/unauthorized. A self-change or possible safety issue invokes the exact protected route while the literal report remains intact.

Automation and human work. Same shared M03-M06 intake. Software structures complex schedules without flattening tapers, alternating doses, multi-strength use, PRN limits, or conditional holds. L2 may clarify practical execution only; the clinician judges clinical meaning.

Estimated human minutes. Included in the single M03-M06 band; typical component 3-8 minutes, varying with medication count and schedule complexity.

Completion evidence. One attributable real-world-use assertion per applicable item, explicit unknowns/conflicts, support person/workflow, and every triggered clinical question. A fill, bottle, pillbox, or MAR field does not prove the person's reported use.

M06. Obtain problems, symptoms, barriers, allergies, and prior-reaction reports#

When. During the same applicable intake and whenever a person reports a medication concern, fall, confusion, sedation, swallowing/device problem, access/administration barrier, allergy, intolerance, or prior reaction.

Required facts and provenance. Exact reporter words; product/substance; event or reaction; timing/onset and severity as reported; actions already taken; access or administration barrier; existing allergy/reaction records and conflicts; callback and current location when a safety route may apply.

Procedure. Capture without confirming, dismissing, grading, or assigning causality. Immediate-danger or urgent-advice content uses the universal safety bypass. Other clinical questions route directly to the exact beneficiary-location-authorized RN, behavioral clinician, prescribing clinician, pharmacist, or outside endpoint required for the act. No RN is a universal gateway.

Automation and human work. Software presents approved prompts, retrieves prior records, highlights literal conflicts, and initiates configured connection steps. The first human receives and connects; only the authorized clinician or outside responder supplies the protected judgment.

Estimated human minutes. Routine capture is included in the M03-M06 band. Safety intake/connection by L1 or L2: 3 / 7 / 12. Authorized clinical response: 5 / 15 / 30+, event-driven and counted once in the protected service, not again here.

Completion evidence. Source-faithful report, location/callback when needed, exact route, live acceptance or active failed-handoff recovery, and attributable clinical/outside disposition. A risk score, alert, message send, or handoff attempt is not a clinical result.

M07. Retrieve clinical medication sources#

When. After a supported review occasion and whenever a material clinical source is missing, stale, corrected, or disputed.

Required facts and provenance. EHR medication lists and orders; stop/cancel orders; allergy/reaction records; prior reconciliation; PCP/specialist/facility/home-health records; author, encounter, effective date, receipt date, system, document/version, and supersession/correction links.

Procedure. Retrieve every connected source, preserve the original, and record unavailable or restricted sources. Software deduplicates copies with the same origin but never discards provenance. L1 requests only the exact disconnected record and matches the returned document to the beneficiary and review.

Automation and human work. Connected retrieval and organization are software. L1 performs one shared manual source-pursuit episode when needed. Clinical staff enter only if source meaning requires judgment, not to chase records.

Estimated human minutes. Clean: 0. L1 manual pursuit: 5 / 12 / 25 shared across M07-M09 where possible. L2: 0. Clinical source clarification: event-driven in M14 or the outside-provider route.

Completion evidence. Source manifest, retrieved originals, provenance/as-of dates, unavailable-source list, requests and results, and matched corrections. A generic "records reviewed" note or copied list is insufficient.

M08. Retrieve pharmacy, dispense, and supply sources#

When. For an applicable review when pharmacy or supply evidence exists or when fill, cancellation, shortage, delivery, pickup, access, or possession is relevant.

Required facts and provenance. Pharmacy/supplier identity; prescription/order reference; dispense, partial fill, reversal, transfer, cancellation, backorder, delivery/pickup, quantity/days supply, claim event, source time, and authenticated pharmacy response.

Procedure. Retrieve connected events, distinguish claim from dispense and dispense from possession, and prepare exact factual questions. L1 contacts the verified endpoint only for missing administrative facts. Clinical clarification, substitution, interaction, or treatment questions route to the pharmacist/prescriber within authority.

Automation and human work. Software is the clean path; L1 handles a disconnected fact; the pharmacy/outside professional supplies source-native facts. No navigator or software infers possession or use.

Estimated human minutes. Clean: 0. L1 manual pharmacy pursuit: 5 / 10 / 20, shared with the M07-M09 pursuit episode when applicable. L2: 0. Protected pharmacist/prescriber time is event-driven.

Completion evidence. Source-specific pharmacy/supply events and unknowns, endpoint/authentication, and separately retained order, claim, dispense/handoff, possession, and reported-use states.

M09. Gather transition medication sources#

When. For every transition between residence and a care setting that creates medication work, including late discharge records, rapid readmission, or corrected transition information.

Required facts and provenance. Pre-transition regimen and reported use; facility/emergency administration; discharge/transfer orders and instructions; transmitted prescriptions/cancellations; pharmacy/supply events; household/facility possession; current reported use; pending tests/results; current location and transition dates.

Procedure. Assemble all settings side by side; never select the discharge list merely because it is newest. Record missing documents and conflicts. The packet routes directly to the exact transition actor still governed by O-028; prescribing authority is mandatory whenever the act determines the intended regimen or performs §7.1 reconciliation.

Automation and human work. Software retrieves and aligns sources. L1 pursues disconnected documents. L2 obtains current practical use/context only for the shared human exception. Care Coordination owns the transition episode; Medication owns only its attributable reconciliation/decision/result.

Estimated human minutes. Clean connected assembly: 0. L1 pursuit: 8 / 20 / 40. L2 exception interview: 0 / 10 / 20. Clinical time is counted in M14, not here.

Completion evidence. Setting-separated source packet, missing-source list, current location/use report, exact receiving clinical authority, and link back to the Care Coordination transition. A discharge list alone is not reconciliation.

M10. Match exact medication products and preserve ambiguity#

When. After source collection and whenever names/codes may refer to the same or different product.

Required facts and provenance. Verbatim names/codes; ingredient; strength/concentration; form; route; release characteristic; salt; combination/compound details; label/photo; source and time.

Procedure. Software performs only approved exact terminology mapping. Record exact match, supported candidate match, or unresolved identity. Do not merge different strength, form, route, release, salt, compound, or combination product unless the evidence supports it. Therapeutic equivalence is protected clinical/pharmacy judgment.

Automation and human work. Clean exact matches are software. L1 obtains a missing label or formulation fact. The exact pharmacist or prescribing clinician resolves protected ambiguity when permitted under O-028; otherwise retain the item unresolved for M14.

Estimated human minutes. Exact path: 0. L1 fact pursuit: 3 / 8 / 15. Pharmacist/prescribing-clinician ambiguity review: 5 / 10 / 20, event-driven and not duplicated in M14 when the same clinician resolves it there.

Completion evidence. Identity map with exact/candidate/unresolved status, reason, and provenance. Model similarity, shared ingredient class, or similar name is not an exact match.

M11. Compare every source assertion medication by medication#

When. After sufficient sources are assembled for an applicable review, and again only when a new or corrected source materially changes the comparison.

Required facts and provenance. Every source assertion for identity, order, intended use, supply, possession, reported use, administration, allergy/reaction, symptom, access, and transition context; documented intentional-difference evidence; and source/as-of time.

Procedure. Software creates a literal difference set for omissions, additions, ingredient, strength, form, route, dose, schedule, PRN/hold/stop directions, overlap, substitution, indication, prescriber, supply, administration, and reported use. Mark a difference documented-intentional only when an attributable source says so; otherwise retain unexplained. Do not decide clinical significance or that no difference means no review.

Automation and human work. Exact comparison is software. L1 clarifies administrative facts; L2 clarifies an actual-use or practical report only under the shared exception. The prescribing clinician interprets every material difference during M14.

Estimated human minutes. Clean: 0. Shared L1 clarification: 0 / 5 / 15. Shared L2 clarification: 0 / 5 / 12. No clinical minutes until M14 unless a separate safety event occurs.

Completion evidence. Source-by-source assertion ledger, literal difference set, documented/unexplained basis, and unresolved facts. No source delta, newest-list selection, or AI "clean list" is not reconciliation.

M12. Pursue only the missing material facts#

When. When M07-M11 identifies a missing fact that matters to the applicable review, safety, identity, intended-regimen decision, or required explanation.

Required facts and provenance. Exact missing fact; why it is material; likely source/endpoint; permitted request content; due/return condition; current safe instruction or safeguard where already supplied by a clinician.

Procedure. Request the smallest factual unit from the beneficiary, caregiver, prescriber, pharmacy, facility, or record source. Track delivery, matched response, exact returned fact, refusal/unavailability, and whether the new fact changes the packet. Do not ask L2 to repeat routine source pursuit or ask the clinician to gather data that can be prepared first.

Automation and human work. Software sends and tracks approved requests. L1 performs disconnected administrative pursuit. L2 enters for beneficiary/caregiver ambiguity, distress, disagreement, or a relationship-sensitive question. The clinical owner defines whether a fact is dispensable or the result remains incomplete.

Estimated human minutes. Clean electronic return: 0. L1 pursuit: 5 / 13 / 30. L2 relationship clarification: 0 / 7 / 15. Clinical decision about unresolved materiality is included in M14.

Completion evidence. Request, endpoint, permission, matched response, source-native fact or truthful non-success, packet update, and remaining unresolved material facts. Attempted outreach or a generic response is not completion.

M13. Prepare the clinician reconciliation packet#

When. After M01-M12 establish a supported occasion and the best available source set, or earlier when an urgent clinical route needs a focused packet.

Required facts and provenance. Occasion/scope; identity/location/authority; source manifest; reported-use history; allergy/reaction history; source assertion ledger; exact matches and unresolved identities; literal discrepancies; symptoms and barriers; transition context; missing material facts; current known instructions; original source links.

Procedure. Software builds a concise priority view plus full expandable evidence. It must preserve every contradiction and unknown, distinguish source facts from summaries, and name the exact question requiring judgment. Readiness outcomes are: ready for M14; missing facts visibly retained for a possible clinician-authored incomplete result; further factual pursuit requested without blocking unaffected medication work; urgent focused route; wrong/unauthorized clinician; or source-sufficiency rule gap held under O-028. Missing medication facts do not automatically prevent the clinician from stating that reconciliation is incomplete, the current instruction that remains applicable, or that no safe new instruction can be released.

Automation and human work. Clean assembly and readiness checks are software. L1 corrects a factual source/link error; L2 corrects only that person's own report/context. The clinician reviews, but does not rebuild, the packet.

Estimated human minutes. Clean: 0. L1 correction: 0 / 3 / 8. L2 correction: 0 / 3 / 8. Clinician orientation time is counted in M14.

Completion evidence. Source-linked packet, exact review question, preserved conflicts/unknowns, readiness or held reason, and routed authorized clinician. A summary, risk score, or assigned task alone is not ready-for-reconciliation proof.

M14. Perform prescribing-authority reconciliation#

When. When a supported §7.1 or otherwise approved reconciliation occasion exists, the best available packet is ready, the beneficiary's current location is known, and the performing clinician has prescribing authority for the act. Immediate safety work may precede or run beside reconciliation.

Required facts and provenance. Full M13 packet; current clinical goals and relevant clinical data; discrepancies and missing facts; beneficiary preference; exact prescriber/treatment ownership; monitoring needs; and the clinician's identity, credential, organization, location authority, and scope.

Procedure. The clinician reviews the packet and, for each medication/substance, determines the current applicable instruction and any recommended continue, start, stop, hold, change, or conditional-use disposition; records exact dose/route/frequency/purpose/effective timing; dispositions every material discrepancy; preserves separate reported use, supply/possession, and administration facts; identifies rationale and monitoring; and states what remains unknown. A recommendation awaiting agreement/order/choice is labeled proposed, not current instructions. The clinician executes judgment—this is not a blessing of an AI/L1/L2 draft.

Automation and human work. Software navigates evidence, displays comparisons, and records the clinician-authored determinations. L1/L2 are absent from clean clinical review unless the clinician requests a missing factual or participant clarification. Only the exact beneficiary-location-authorized prescribing clinician performs reconciliation.

Estimated human minutes, with minute-by-minute composition. Low case 12 minutes: orient to packet 3, review/disposition 7, author result/monitoring 2. Ordinary case 25 minutes: orient 4, resolve discrepancies and regimen 15, author result/monitoring 6. Complex case 45 minutes: orient 5, multi-source/multi-clinician judgment 30, author result/safeguards/monitoring 10. Additional treatment work outside reconciliation is separate.

Completion evidence. Clinician-authored intended regimen, medication-level dispositions, every material discrepancy resolved or explicitly retained, rationale, monitoring, separate real-world facts, identity/authority, date/time, and M15 result. Time spent or electronic sign-off alone is not reconciliation.

M15. Record the truthful reconciliation result#

When. Immediately after M14 and again only when the clinician authors a corrected or superseding result.

Required facts and provenance. M14 medication-level dispositions; material-discrepancy inventory; unresolved sources/questions; current instruction; ability or inability to release a new instruction; safeguards; owners; monitoring and follow-up.

Procedure. The clinician-authored review result is exactly one of: complete without change; complete with change recommended or already authorized, explicitly distinguished; or incomplete. No-change requires every material discrepancy disposition. A completed change recommendation does not authorize its implementation; record its origin, pending gates and current applicable instruction separately. Incomplete must state the current instruction that remains in effect or that no safe new instruction can be released, plus unresolved questions, safeguards, owner, and return condition. Software may draft the classification record but cannot choose it.

Automation and human work. This is part of the same M14 clinical episode. Software validates required fields and routes downstream obligations. L1/L2 may pursue those obligations but do not reclassify the clinical result.

Estimated human minutes. Clinician 1 / 3 / 7 component minutes included inside M14, not a separate review. L1/L2: 0 here; later factual pursuit is counted under M12 or the receiving service.

Completion evidence. Attributable classification, supporting discrepancy dispositions, current instruction/no-safe-new-instruction statement, safeguards, owners, and follow-up. "Reviewed," clinician acknowledgement, comparison complete, or no source delta is not a result.

M16. Explain the result and return it to the person and affected work#

When. After M15 supplies an authorized result, and again when a corrected result or returned answer materially changes what the person must understand. Do not present a proposal or incomplete draft as active instructions.

Required facts and provenance. Clinician-approved explanation; current instruction; what changed/did not change/remains uncertain; effective timing; safeguards and monitoring; permitted recipients and disclosure scope; language/accessibility; beneficiary/caregiver questions; exact affected Assessment, Care Plan, Care Coordination, Ongoing, pharmacy, facility, or outside-provider return.

Procedure. The clinician may explain that clinician's own result directly within authority and answers protected questions. A separate L2 delivery/reinforcement, caregiver or facility disclosure, changed destination, corrected content, or other medication-result release remains held wherever the exact O-030 communication performer and release rule is unresolved. When an approved route applies, L2 may reinforce exact content, address access/scheduling/practical supports, and conduct a bounded understanding check without adding clinical meaning. New clinical questions return to the clinician. Each affected pillar receives the source-linked result and opens only its own necessary work; explanation does not prove order execution, possession, use, or monitoring.

Automation and human work. Software renders accessible approved content, applies already approved recipient/channel rules, records delivery, and tracks questions/returns. It does not infer comprehension or authorize an unresolved release class. L2 enters only under an approved O-030 route for human explanation/support; the clinician enters for clinical meaning or unresolved questions.

Estimated human minutes. L2 approved explanation/support: 3 / 8 / 15. Prescribing clinician explanation: 0 / 7 / 15 for no-change/ordinary questions and 10 / 20 / 30 when change, uncertainty, or complex medical questions require clinical discussion. Shared clinician/L2 interaction minutes are counted once by actual performer.

Completion evidence. Exact content and source; performer; recipient/authority; accessible delivery; questions and answers/routing; person-stated understanding or remaining uncertainty; next action; and each cross-pillar return. Delivery, "do you understand," portal availability, or navigator paraphrase alone is insufficient.

Human time — shared episodes#

These low / ordinary / complex ranges are planning assumptions, not CMS minutes, clinical deadlines or quotas. They estimate the actual Proxi-paid work when that branch occurs. Beneficiary/caregiver effort and outside organizations' work are not included as Proxi labor unless Proxi supplies/contracts that performer. Record occupied call/hold time in the actual worker's paid time; elapsed days awaiting a response are not themselves human minutes.

Do not sum every card's range. A single clinician decision may satisfy M14, M17, M18, M24 and M36; a single person conversation may satisfy M16, M25, M30 and M32; a single pharmacy call may satisfy M08, M23, M28 and M35. Record one actual episode by performer and attach its distinct outputs to the applicable tasks. Add only a genuinely separate act.

Task-level operating cards — M17–M31#

The following cards reuse the clinical checklist and shared procedures through exact links. Each applies only when its stated trigger exists. A completed no-change review does not open a medication-change, order, pharmacy or extra clinician episode automatically.

M17. Consider a beneficial medication#

When. The prescribing review or a focused clinical question raises whether an additional treatment would benefit this beneficiary; do not create a new review merely from a drug-rule match or a billing month.

Purpose and inputs. Obtain the actual prescribing judgment. Prepare the current regimen and reported use, goals, indication/source, prior benefit/problems, allergies, relevant clinical data, access constraints, preferences, missing facts and exact question.

Procedure.

1. Software prepares the source-linked question using the prescribing checklist; it does not rank treatments clinically.
2. The beneficiary-location-authorized L4 clinician acting as the Participant's APN, PA or physician determines not clinically advisable, change advisable, or insufficient basis for a decision.
3. The clinician records rationale, current instruction, proposed treatment/timing/monitoring if any, and needed evidence or safeguards.
4. Send a proposal to M19; return a no-proposal result to the requesting task; send missing facts to M12 and keep only the affected clinical conclusion incomplete.

Automation and people. Software prepares and records; only the actual authorized clinician exercises judgment. L1 pursues requested facts; L2 enters only for a separate D-021 person-facing need. No new specialist or generic RN review is created.

Human minutes. The shared additional-treatment band is 5 / 15 / 30 when this is a separate decision; 0 incremental when M14 already supplied it. Ordinary composition: orient 3, judge 9, record/return 3.

Completion / failure. An attributable clinical disposition, rationale and exact next route complete this consideration, not a prescription or implementation. Unknown authority is held under O-028; missing prerequisite evidence yields a bounded incomplete result, not an AI suggestion.

M18. Determine whether a medication should be deprescribed#

When. An actual prescribing review raises whether continuing an item is inappropriate. A performance-measure or interaction match alone is a candidate for review, not a stop instruction.

Purpose and inputs. Avoid inappropriate therapy without an unsafe unplanned stop. Prepare exact product/current instruction, indication, duration, reported benefit/problem, current use/supply, relevant clinical data, withdrawal/taper question where applicable, other prescribers, preference and unknowns.

Procedure.

1. Software assembles the product-specific question and original sources; preserve the distinction between a clinical recommendation and a currently effective stop.
2. The actual Participant APN, PA or physician within beneficiary-location authority determines continue, clinically advisable deprescribing, or decision deferred pending named evidence.
3. The clinician authors the applicable stop/taper/monitoring proposal or the reason no change is recommended; nonclinical staff never design a taper.
4. Use the GUIDE-originated change procedure for a new recommendation. Preserve existing supply, packaging and reported use for M28–M31 rather than assuming a cancellation removes medicine from the home.

Automation and people. L0/L1 prepare facts; the exact L4 professional decides. An outside pharmacist may supply a scoped pharmacy fact or recommendation but does not become the prescriber without actual authority.

Human minutes. Same 5 / 15 / 30 treatment-decision episode as M17 or M14 when performed together; do not add another band for the same judgment.

Completion / failure. Record the clinical disposition and proposed/current instruction distinctly. Advisable deprescribing remains unexecuted until its applicable agreement, order, person-choice, instruction and supply/use steps are resolved. Missing clinical basis or authority remains explicit; safety work proceeds independently.

M19. Prepare the proposed medication change#

When. The authorized clinician has authored a GUIDE recommendation; an outside order, outside recommendation or self-change retains its own route.

Purpose and inputs. Give providers and the beneficiary one faithful proposal, not several competing versions. Required content: exact medicine/product; current versus proposed dose/route/schedule; rationale; effective timing; conditions; monitoring; author/authority; source/evidence; person preference; and unresolved items.

Procedure.

1. Software structures only the clinician-authored content using the GUIDE-originated change procedure.
2. Check for missing product, rationale, timing, conditional directions, monitoring or proposal identity. Return only the missing clinical content to its author; never fill it from AI inference.
3. Label the content proposal — not active instructions while applicable agreement/order/choice gates remain open.
4. Send the exact proposal to separate M20 sharing-recipient and M21 agreement-provider work; retain any earlier person-decline or pending clinical question.

Automation and people. Clean preparation is software, not another clinician review. L1 corrects a broken source link or administrative field. The author supplies missing clinical content in the same clinical episode.

Human minutes. Clean 0; L1 factual correction 0 / 3 / 8 when separate; clinical correction is counted once in the M17/M18/M24 or originating review episode.

Completion / failure. Exact source-linked proposal, author, distinct current instruction, complete fields or named gap, and separate receiving work. A polished AI draft, pharmacy instruction or old agreement cannot complete this task or activate the regimen. A changed proposal invalidates responses that do not match it.

M20. Identify recommendation-sharing recipients#

When. A GUIDE-originated medication recommendation requires §7.4 sharing.

Purpose and inputs. Relevant clinicians receive the recommendation without assuming each must approve it. Prepare current PCP/specialist relationships, treatment/indication links, endpoints, last-confirmed dates, exact proposal and known responsibility statements.

Procedure.

1. Software retrieves known treatment relationships and prepares the applicable sharing list separately from M21's agreement list.
2. L1 verifies a disconnected office, endpoint, provider change or objective relationship fact. A direct attributable beneficiary report can supply a relationship fact without a mandatory navigator call.
3. The proposing clinician resolves only a real question of clinical applicability; O-029 governs unapproved same-provider, multiple-provider or disputed-responsibility patterns.
4. Preserve each recipient and required/uncertain basis; send the sharing list to M22. Do not erase a sharing obligation because that clinician is not an agreement authority.

Automation and people. Connected matching is software. L1 handles actual factual pursuit; L2 only a D-021 relationship/accessibility/requested-help exception. Clinical relevance goes to the proposing clinician, not a generic coordinator.

Human minutes. Clean 0. Share the M20–M24 L1 0 / 7 / 20 and triggered clinician 0 / 5 / 15 bands; ordinary L1 episode is verify 2, contact 3, record 2, not seven minutes for each recipient/card.

Completion / failure. Recipient-specific sharing list, basis, source/as-of date and verified endpoint or exact unresolved gap. Wrong/old endpoints remain held for correction. The list does not prove release, receipt, provider agreement or permission to change medication.

M21. Identify the relevant provider whose agreement is required#

When. The exact GUIDE recommendation needs the relevant PCP or medical specialist's agreement before the beneficiary changes medication.

Purpose and inputs. Obtain the right clinical concurrence rather than collecting signatures from every doctor. Prepare the proposal, indication, current orders, treating relationships, co-management/responsibility statements and M20 sharing list.

Procedure.

1. Software displays which providers have the source-supported relationship; it does not assign outside responsibility.
2. The proposing clinician applies the approved O-029 policy to identify the exact agreement provider(s) and basis. A share-only specialist is not automatically an agreement provider.
3. Retain same-provider, multiple-provider, transferred-care, no-accepted-owner and responsibility-disputed cases separately. If the policy has not resolved the case, hold only this gate as design-blocked while permitted preparation/sharing continues.
4. Send the exact agreement request to M22/M23 after the release route is approved. An outside provider accepts or disputes responsibility within that provider's authority.

Automation and people. L1 verifies factual relationships; the authorized clinician supplies clinical relevance/responsibility judgment. No obligatory second clinician is invented when the proposing clinician and relevant PCP may be the same; the actual O-029 rule must resolve that case.

Human minutes. Same shared M20–M24 episode; 0 incremental if the clinician already recorded the applicable provider in the original proposal. Additional clinical question uses 0 / 5 / 15.

Completion / failure. Exact agreement-provider list and approved basis, or a specific unresolved ownership/policy result. Silence or office receipt cannot settle responsibility; unresolved scope never grants permission.

M22. Release the recommendation to applicable providers#

When. M19–M21 provide the unchanged clinician-approved proposal, selected sharing/agreement recipients, verified endpoints and lawful recipient/purpose authority; the O-030 class rule and any genuinely required individual review must be accepted.

Release basis. D-033 selects automatic approved-rule sending of an unchanged US-clinician-approved recommendation to the selected authorized PCP/specialist, without an extra per-packet OK. Clinical approval alone is not sharing permission or provider agreement. O-030 must establish the actual accepted class/basis and any genuinely mandatory human-review condition. Patient orders/counseling, Care Plans, community referrals and special/uncovered content keep their own requirements. Approval and sending separates these acts; independently due clinical work is not waived.

Purpose and inputs. Each intended clinician receives the same attributable recommendation and exact response request. Inputs include unchanged clinical content, author, proposal identity, recipient role, permission/purpose, channel, prior sends and any correction/re-send.

Procedure.

1. Software assembles the smallest authorized packet and validates objective destination/content fields.
2. Software applies the accepted D-033/O-030 sharing rule to the exact packet. Missing, conflicting or uncovered facts hold the affected send. If a controlling requirement mandates individual human review, obtain it from the actually authorized person first; an unapproved required role/class remains SOP DESIGN BLOCKED — NOT OPERATIONAL, not an invented navigator/RN/privacy reviewer.
3. After approved-rule authorization and any genuinely required review, software transmits automatically without another per-packet OK. If automated transmission is unavailable, Philippine L1 manually sends the unchanged recommendation to the already-selected authorized PCP/specialist under D-031 and records actual send/delivery/failure. This does not include a new patient order, counseling, selecting the clinically relevant provider, changing the recommendation or independently resolving provider agreement.
4. Track clinical content approval, class/sharing basis, any required review, send, technical delivery, named receipt and requested response independently for each recipient.
5. For failed or changed-destination delivery, L1 repairs the factual endpoint. Re-check the exact packet, destination and sharing basis before re-send; obtain any actually required human review. A covered D-033 resend needs no extra OK when the accepted rule permits it. Keep unaffected recipients' results.

Automation and people. D-033's approved-rule clean transmission has no extra human release check. Software prepares, authorizes only under the accepted rule, transmits and tracks; AI never determines permission or medical sufficiency. D-031 assigns L1 only manual provider transport when automation is unavailable, not authority to resolve missing permission. A genuinely mandatory individual review uses its actual accepted performer. Clinical authorship is not a second generic release review; returned clinical uncertainty/disagreement uses the actual professional route, while faithful receipt capture alone does not buy another clinician review.

Human minutes. Clean D-033 rule-based sending: 0 extra human release minutes, not zero clinical-authoring or manual-transport work. The existing 1 / 2 / 5 band applies only to an actually required, approved separate human review not already included in direct clinical communication. Repair time shares M20–M24 pursuit, not one band per destination.

Manual transmission is actual paid L1 work in that shared administrative episode; record it once with preparation/endpoint/receipt work. Do not call it zero because clinical approval already exists, duplicate it per destination, or borrow the clinician's release minutes. Existing pursuit bands are planning references, not a cap on actual work; occurrence/minute calibration remains O-039.

Completion / failure. Exact accepted class/sharing-rule basis, evidence of any genuinely required individual review and each required destination's truthful outcome. Delivery/receipt does not prove agreement. Missing authority or exhausted configured recovery remains open with person-facing status under the permitted channel; no invented timeout approves change.

M23. Obtain and authenticate the provider response#

When. A valid exact-proposal agreement request has been released, or a provider response arrives through the approved route.

Purpose and inputs. Know what the relevant provider actually agreed to. Preserve responder identity/organization/authority, proposal identity and scope, response time/content, response channel, effective period and any later correction/revocation.

Procedure.

1. Software matches the source response to the current proposal, beneficiary and required provider; retain original words.
2. Record exact agrees, modifies, declines, no response, revoked, wrong provider/scope/proposal, stale or unauthenticated evidence. If classification needs clinical interpretation, retain it pending the proposing clinician's reading.
3. L1 pursues only disconnected source/identity/delivery/status facts. Office staff's receipt is receipt, not clinical agreement.
4. A current exact valid agreement proceeds to the remaining M25/M26 gates. Every modified, invalid, absent or disputed response goes to M24; valid response from one provider does not satisfy a separately required response.

Automation and people. Software matches complete objective evidence under approved rules. The relevant PCP/specialist supplies the protected response; the proposing clinician interprets ambiguous/conditional content. L2 is not a routine response chaser.

Human minutes. Use the shared M20–M24 L1 0 / 7 / 20 and triggered clinician 0 / 5 / 15 episode. Outside provider work is separately recorded; it is not silently counted as Philippine labor or assumed Proxi-funded.

Completion / failure. Attributable current response or truthful nonresponse/invalid result plus next action. Silence, old approval, a fax receipt or expired response is not agreement. Follow O-005/O-029's approved clock; until approved, no operational retry or expiry is invented.

M24. Resolve a modified, declined, missing, stale, or invalid response#

When. M23 does not establish all required current exact agreements, or an agreement is later revoked.

Purpose and inputs. Avoid incompatible treatment and explain the actual next step. Prepare the exact proposal/response, provider disagreement/responsibility, attempts, current clinical instruction, symptoms/use as reported, person preference, and missing facts.

Procedure.

1. Software keeps the proposed change inactive under MED-041 and separates the response defect from independent sharing and safety work.
2. L1 repairs a purely factual defect or pursues status under the approved policy; no clinical review is added for a corrected fax number alone.
3. The proposing clinician handles clinical modification, decline, conflicting advice or unresolved current course. A modified recommendation becomes a new proposal and its prior agreement does not carry forward automatically.
4. Record new proposal, withdrawn proposal, declined, concurrence not obtained, evidence pending or other approved disposition. The clinician states the applicable current instruction or inability to release a safe new instruction and any safeguard/follow-up.

Automation and people. Software tracks; L1 obtains facts; the actual prescribing/treating clinicians make clinical decisions. L1/L2 may not tell the person to continue an old regimen merely because the proposal is blocked; the applicable current course must come from its authorized source.

Human minutes. Factual repair shares M20–M24. A separate substantive clinical decision uses 5 / 15 / 30, or 0 incremental when included in the same original review or provider discussion.

Completion / failure. Exact clinical/factual disposition and remaining gates, person-facing permitted status, current course/safeguard and next owner. Nonresponse can end a pursuit truthfully but never grant agreement or complete a medication change.

M25. Review the proposal or agreed change with the beneficiary#

When. A proposal is ready for person discussion, or an agreed/current change needs final explanation and choice before non-emergency implementation or release as active instructions.

Purpose and inputs. The person understands the actual proposal, benefit/burden and remaining conditions, and makes the decision within their authority. Prepare exact current/proposed content, agreement/order status, clinical explanation, costs/access limits, accessible mode, speaker/decision-specific representative evidence and questions.

Procedure.

1. Clearly state whether this is a proposal, agreed recommendation, lawful order or current instruction. Preliminary willingness to explore a proposal is not final implementation authority.
2. Capture accept, refuse, defer, request medical explanation, request an alternative or unresolved authority. A clear attributable response through an approved mode creates no mandatory L2 confirmation.
3. The authorized clinician authors the medical explanation. An approved faithful digital/asynchronous or care-team reinforcement route may deliver it; the clinician joins for individualized medical questions, uncertainty or an actual required clinical act. No extra live consultation is inferred for every proposal. L2 supports only an approved O-030 reinforcement or real D-021 need; caregiver disagreement is retained, not automatically a veto.
4. Return early refusal to the clinician for disposition. Distinguish a withdrawn proposal from a still-current recommendation with a sharing duty, and preserve only an actually applicable clinician-authored counseling/safety duty; do not manufacture a counseling call or pursue implementation as if accepted. Reconfirm the exact final proposal if a provider modification changes it.

Automation and people. Software presents approved content and captures person responses within the approved communication/authority matrix. The beneficiary or decision-specific representative chooses; clinicians exercise medical judgment; an unapproved digital/release mode remains held.

Human minutes. Actual additional medical conversation shares M25/M26 7 / 15 / 30 and any already counted M16 discussion; order-only work uses M26's 1 / 2 / 4 component. Separate L2 exception 0 / 5 / 12. Approved faithful delivery/direct choice adds 0 navigator minutes and no automatic clinician conversation.

Completion / failure. Exact content/status explained, respondent/authority, attributable choice/questions and next route. Refusal, incomplete understanding or authority conflict remains truthful and cannot activate the proposal. Person choice and lawful order remain separate milestones.

M26. Issue the prescription or stop order#

When. An authorized prescriber decides to issue a lawful current order under the applicable origin-specific policy. A GUIDE proposal requires the exact §7.4 agreement; an outside order or approved emergency route retains its separate authority.

Purpose and inputs. Produce the legal execution artifact without treating agreement or a draft as a prescription. Prepare exact product, dose/route/schedule/conditional directions, author/authority, proposal and agreement evidence, recipient pharmacy/facility, effective timing, monitoring and person-choice status.

Procedure.

1. Validate the prescriber's current beneficiary-location/prescriptive authority and the origin-specific prerequisites.
2. The prescriber authors and authenticates the prescription, revised order, discontinuation or cancellation; software may populate from the prescriber's exact instructions but cannot prescribe.
3. Keep order issuance separate from person choice. The current design requires choice before active non-emergency instructions/implementation; it does not infer a universal legal rule that an order cannot be authored before that choice. O-029/O-030 must settle any stricter organizational sequence.
4. Send the exact order to M27. If refusal or changed proposal affects an existing order, the prescriber supplies the cancellation/revision and resulting instructions; software never silently deletes it.

Automation and people. Exact authorized L4/outside prescriber authors the order. L1/L2 neither signs nor converts a recommendation into an order. O-028 controls the approved performer.

Human minutes. Order authoring is a 1 / 2 / 4 component inside the same M25/M26 clinical episode when performed there; separate necessary order work uses actual incremental time, not another whole consultation.

Completion / failure. Authenticated exact lawful order/cancellation, author/authority, effective timing and linked prerequisites/person status. No transmission, fill, acquisition, understanding or use is inferred.

M27. Send the order or cancellation for execution#

When. M26 or an authenticated outside source provides the exact lawful order/cancellation and its approved transmission route.

Purpose and inputs. Get the prescriber's order to the right executing pharmacy/facility without duplicate or altered commands. Inputs include order identity/content, verified recipient, permitted route, effective status, prior sends, technical acknowledgements and correction/re-send authority.

Procedure.

1. Software transmits through the approved prescribing integration and records each technical outcome separately from pharmacy execution.
2. A clean matched acceptance proceeds to M28 with no L1 call. Unknown state, rejection or outage remains unknown; check matched status before a permitted retry.
3. L1 repairs only a disconnected administrative endpoint/status fact. Configuration/access failure goes to the System Administrator; an actual product defect goes to Software Engineering, not a care navigator.
4. Clinical rejection or clarification routes to the exact pharmacy/prescriber act. Changed clinical content returns to its author, with new lawful artifact/release as required.

Automation and people. Clean send and tracking are software under the approved route; L1 is exception-only. A technical acknowledgment does not authorize a clinical substitution or prove dispense.

Human minutes. Clean 0. L1 repair shares the M27–M29 0 / 7 / 20 band; no extra seven-minute episode for each status message. Protected clinical work is counted only where it occurs.

Completion / failure. Exact order/destination/send and source-native technical result, or explicit unresolved state/approved recovery. A cancellation acknowledgment does not prove household stop or disposal. O-031 governs retry and uncertain-response behavior; no new timeout or duplicate-send policy is invented.

M28. Confirm pharmacy execution#

When. A pharmacy/supplier receives the order/cancellation or a source-native execution event arrives.

Purpose and inputs. Learn what actually happened so the person is not told medicine is available or stopped when it is not. Preserve exact order/product/pharmacy, event/receipt dates, quantities, partial status, source and response.

Procedure.

1. Software records technical acceptance, clarification, preparation, partial/full fill, emergency/trial supply, transfer, backorder, return-to-stock, cancellation, dispense/handoff and unavailable/unknown as distinct evidence.
2. L1 pursues only a disconnected factual status or delivery/access problem. A claim or preparation message does not prove handoff, possession or use.
3. The named pharmacist or prescriber handles clinical clarification/substitution within actual scope; a therapeutic change requires lawful prescribing authority and its origin-specific gates.
4. Return exact supply facts to M31 and any access barrier to M34/M35. For a stopped medicine, retain remaining household/facility stock, pillbox/MAR and reported-use questions rather than assuming the pharmacy cancellation solves them.

Automation and people. Connected status is software-only. L1 handles factual pursuit. Outside pharmacy staff supply their own facts; pharmacist/prescriber judgments are separate, not a default Proxi L4 logistics review.

Human minutes. Same shared M27–M29 L1 0 / 7 / 20 repair episode. An actual pharmacist/prescriber consultation is measured separately by its performer and is not assumed free or automatically Proxi-paid.

Completion / failure. Attributable exact pharmacy disposition and still-unknown possession/use, with receiver/next action. Partial fill, promise, accepted order or cancelled claim does not complete supply or treatment implementation. Unknown/outage state follows O-031 and the clinical safe-course instruction if needed.

M29. Synchronize the medication and care records#

When. An authorized clinical result, order, corrected instruction or source update changes a required destination. Synchronization faithfully propagates content; it is not a new clinical reconciliation.

Purpose and inputs. The beneficiary, clinicians, pharmacy and authorized helpers see the right current instructions without erasing distinct real-world facts. Prepare exact authored result/current-versus-proposed status, affected destinations, recipient permission, clinical record authority, source/effective timing and prior transmitted content.

Procedure.

1. Determine each actually required destination: EHR, Care Plan, pharmacy, beneficiary, permitted caregiver/representative, facility/MAR, schedule support and applicable treating clinician.
2. Software prepares destination-specific faithful updates. Apply each approved clinical-record and O-030 release rule; unresolved performer/class blocks only that destination.
3. Record update/release, delivery/access, acknowledgment, correction and failure independently. An EHR update does not prove a pharmacy or caregiver received it.
4. Follow Care Plan's beneficiary-led direct-choice/actual-human-help procedure when plan wording changes; no blanket L2 or clinician blessing is added to a faithful approved update.
5. A clinical conflict returns to the author. A disconnected endpoint/status goes to L1; genuine integration/configuration or product failure goes to the actual technical job.

Automation and people. Software executes the approved clean update; exact human release/record acts occur only when the class requires them and the performer is approved. Source authorship is preserved.

Human minutes. Clean 0 beyond any required bounded V1 release; L1 repair shares 0 / 7 / 20 with M27–M29. Person discussion or clinical correction is counted once in its actual episode.

Completion / failure. Destination-specific attributable update/receipt or truthful non-success and next action. Do not overwrite reported use, supply or administration with the intended regimen; keep independent recipients' successes when one fails.

M30. Give final medication instructions and confirm understanding#

When. The exact current instruction may be communicated through its approved route. A non-emergency GUIDE change needs required agreement, lawful current order and person choice before being released as active instructions.

Purpose and inputs. The person or authorized administrator knows what to do and how to obtain help. Prepare exact clinician-authored directions, current/proposed status, affected old supply, language/accessibility, permitted recipient, conditional regimen details, missed-dose/problem instructions only if authored, monitoring and questions.

Procedure.

1. Use the accessible instruction and teach-back procedure. The authoring clinician may explain directly; separate reinforcement/release requires the approved O-030 route.
2. Ask the beneficiary or permitted helper to explain applicable medicine, amount/route/timing, PRN/hold/taper conditions, affected supply and monitoring/help route in their own words. For a professional/facility recipient, obtain its role-appropriate authenticated receipt, order/MAR incorporation or required demonstration rather than imposing caregiver-style teach-back universally.
3. For a practical/accessibility misunderstanding, the approved L2 navigator reinforces unchanged content and rechecks. Clinical meaning, device/formulation questions, nursing assessment, prescribing questions and immediate safety use their exact professional routes; refusal is not automatically an RN task.
4. Record demonstrated understanding, partial understanding, unavailable recipient, refusal, needed helper or unresolved question. Never infer legal incapacity from failed teach-back alone.

Automation and people. Software renders approved accessible content and retains the response; it does not judge clinical comprehension or fill in a missing instruction. The actual approved person performs the bounded human explanation/check.

Human minutes. Shared M30/M31 L2 0 / 8 / 15 or the already-counted medical discussion; new clinical work 0 / 10 / 25 only when triggered. Ordinary L2: explain 3, plan-back/barrier 3, record 2.

Completion / failure. Exact content, author/release/performer, recipient/authority, accessible delivery and attributable understanding/remaining gap. A sent summary or yes/no answer is insufficient. Keep instruction open until its actual result; return new questions directly without repeating the full intake.

M31. Confirm implementation and complete monitoring#

When. A specific medication decision or clinical plan creates a due real-world follow-through or monitoring obligation; not every no-change review needs a new lab, call or clinician.

Purpose and inputs. Know whether the person could implement the regimen and whether due monitoring was actually reviewed. Prepare exact current instruction, source-native order/supply facts, person/helper report, clinical monitoring order including applicability/collector/reviewer/due time, results and unknowns.

Procedure.

1. Capture obtained/possessed/started/stopped/delayed/refused/self-changed/unknown reports separately; preserve actual administration only when its source supports it.
2. Record monitoring not required, not yet due, input pending, invalid/missing, valid result awaiting review, or professionally reviewed. The clinician—not silence or software—supplies not-required or changed-plan applicability.
3. Software retrieves and tracks; L1 pursues disconnected results; L2 supplies required/requested practical follow-through. The authorized professional interprets a valid due result and returns action/no-change, explanation and the next due condition.
4. Clinical symptoms, refusal, self-change or contradictory use go to the exact clinical/safety act. A posted lab or reminder is not professional review.
5. Return the actual implementation and monitoring milestones separately to the affected Care Plan, Ongoing or transition task. An upcoming future cycle stays owned without invalidating the earlier M14–M15 result.

Automation and people. Use the monitoring procedure. No clinician enters when no monitoring or new clinical question is required; no L2 duplicate call when an attributable approved result already answers the due practical question.

Human minutes. Clean status 0. Actual L2 support shares 0 / 8 / 15 with M30; due protected interpretation 0 / 10 / 25 by its actual performer, not automatically an L4 visit.

Completion / failure. Each applicable implementation result and each due monitoring disposition/action/communication, or an explicit authorized unresolved/revised plan with safeguards. A lab-only obligation does not require a manufactured new possession/use interview. Future due, unread, stale, declined and missed results remain distinct; only the relevant obligation closes, not every future monitoring cycle.

Task-level support and safety cards — M32–M38#

M32. Offer medication-schedule support information#

When. A current authorized regimen is available and schedule-support information is due at service entry, a new regimen/support need makes it useful, or the person requests it. Record a decline without forcing the conversation; do not repeat an already current information offer merely because another review occurred. Applicability and offer evidence remain O-033, not a new CMS contact frequency.

Purpose/value and required facts. Provide the §7.5 navigator information service so the person can compare usable ways to follow the authorized schedule without changing clinical directions. The packet includes the regimen/version and source, schedule complexity, existing support, accessibility/language needs, technology access, caregiver or facility participation, and stated preferences. A caregiver may report or help but does not choose unless separately authorized.

Procedure.

1. Software presents the source-linked authorized schedule and flags tapers, alternating doses, PRN limits, conditional holds, multiple strengths, or other directions that must not be flattened.
2. The Puerto Rico GUIDE navigator explains approved reminders, calendars, pill organizers, pharmacy packaging, or applications and their practical limits, without recommending treatment or altering timing.
3. The beneficiary or authorized representative selects, declines, defers, requests another accessible option, or leaves the choice unresolved.
4. Route a selected setup to M33. Route any clinical question directly to the exact prescribing clinician. If an approved result must be released to a new recipient, apply O-030 rather than treating this conversation as release authority.

Automation and human work. Software prepares options and records the choice. M32 itself is a real L2 navigator information act. L1 does not substitute for it.

Shared minutes. Prepared information only: low 1 for one useful option/current-method confirmation and attributable response; ordinary 4: explain 2, practical question 1, record/route 1; complex 10: accessible/conditional-schedule explanation 5, preference/support questions 3, record/route 2. Actual assisted setup is a separate component only if needed. Count the combined M32/M33 interaction once; do not book 12–25 minutes for a clean one-option information act.

Completion/failure/return. Complete only with attributable options explained and an authenticated select/decline/defer/unresolved result. A sent link is not completion. Unusable options return to M32; selected setup opens M33; clinical content returns to the prescriber.

M33. Help set up the selected schedule support#

When. After M32 records a beneficiary- or authorized-representative-selected support compatible with the current regimen. Do not configure from a proposal, stale regimen, or caregiver preference alone.

Purpose/value and required facts. Make the support usable without turning it into a medication instruction. Required facts are the selected support, current regimen/version and conditional directions, intended user, permitted helpers, accessibility/technology constraints, setup party, and usability check.

Procedure.

1. Software verifies that the selected support can represent the current schedule without flattening a taper, alternating-day plan, PRN maximum, multiple strengths, or conditional hold. An unusable taper reminder returns to M32 or the clinician; software does not simplify it.
2. For a supported digital reminder or application, software configures only authorized content and asks the beneficiary to confirm the display and alerts.
3. Route physical packaging, organizers, devices, or facility workflow to the named permitted caregiver, pharmacy, facility, or external party. L2 assists only when requested or needed for accessibility, demonstration, or relationship-sensitive coordination.
4. Record usable, unusable, declined, abandoned, or setup-pending. A clinical-direction conflict stops setup and returns the question to the prescriber.

Automation and human work. Clean digital setup is software-only. L1 may repair a disconnected account, delivery, or vendor-status fact but does not populate directions. L2 may demonstrate approved use without choosing treatment. Actual medication sorting/filling or pharmacy packaging uses the specifically permitted performer under O-028/O-033; navigator status alone does not authorize that act. A caregiver assists but cannot decide absent representative authority.

Shared minutes. Low 0 for clean digital setup. Actual separate human setup: ordinary 8: confirm support 2, assist 4, usability 2; complex 15: accessible demonstration 7, correct nonclinical problem 5, recheck/record 3. If performed with M32, use the actual combined components once; do not add another whole information/support estimate.

Completion/failure/return. Complete only when the selected support is configured by the actual party, the beneficiary can access/use it, and regimen/version provenance is retained. Setup pending, unusable, or clinically conflicting remains open and returns to M32, the external setup party, or the exact clinician.

M34. Identify a medication-access barrier#

When. When the beneficiary/caregiver reports difficulty obtaining the authorized supply, or a source shows a possible cost, coverage, authorization, shortage, transport, pharmacy-location, delivery, packaging, or supply problem. Missing fill or failed claim is a candidate barrier, not proof.

Purpose/value and required facts. Identify the smallest obstacle so administrative help can begin without labeling nonadherence or selecting treatment. Preserve medication/order identity and version, reporter/source/time, pharmacy or supplier, benefit/claim status, expected versus actual supply event, possession report, affected timing, current instruction, and any safety cue. “No transport to pickup” remains a transport report, not a medication decision.

Procedure.

1. Software compares order, pharmacy, claim, delivery, and reported-possession facts and asks a bounded accessible question.
2. Record the person's exact answer: no barrier, cost, coverage, authorization, shortage, transport, location, delivery, packaging, supply, refusal, unknown, or another source-faithful result.
3. Invoke the M37 safety path immediately for a reported extra dose, acute symptom, or request for urgent advice; do not finish routine intake first.
4. Route a confirmed administrative barrier to M35, a possible treatment/substitution question to M36, and a preference or relationship issue to L2 only under D-021.

Automation and human work. The clean direct screen and connected-data comparison require 0 human minutes. L1 verifies only disconnected objective pharmacy, payer, supplier, delivery, or transport facts. L2 enters only for requested help, ambiguity, distress, disagreement, accessibility, or relationship context. Neither decides clinical significance.

Shared minutes. Clean 0. When bundled with M35, use the shared L1 0 / 12 / 22 episode: ordinary verification 2, contact/repair 8, record/return 2. L2 clarification enters only on its own trigger and is logged separately; the illustrative complex shared episode includes L2 8 plus L1 22. Do not add a second classification band.

Completion/failure/return. Complete with an attributable barrier/no-barrier/unknown result and exact receiving route. A failed claim, attempted call, or inferred possession is insufficient. Unknown or conflicting facts remain open; administrative repair returns through M35 and clinical alternatives through M36.

M35. Coordinate resolution of an access barrier#

When. After M34 establishes a specific barrier and the beneficiary or decision-specific authorized representative wants assistance. A missing claim or late pharmacy event alone does not open M35.

Purpose/value and required facts. Remove or truthfully disposition the barrier while preserving treatment choice for the prescriber and service choice for the beneficiary. The packet contains the barrier, current order/regimen, affected supply milestone, permitted contact/purpose, beneficiary constraints and choice, prior attempts, named endpoint, and any clinician safeguard.

Procedure.

1. Software uses approved connected routes for administrative information, tracks the matched response, and retains each source/status.
2. Philippine L1 contacts a disconnected pharmacy, payer, supplier, transport provider, or assistance program for objective status, missing items, approved resubmission, or route repair. L1 does not suggest substitution or relay a new order.
3. L2 enters only when the beneficiary requests human help or unresolved preference, accessibility, distress, disagreement, or relationship work remains—for example, choosing among two administratively feasible delivery routes.
4. Record resolved, partially resolved, pending external action, declined, unavailable, failed, or clinical alternative required. Route the last branch to M36 without representing it as access resolution.

Automation and human work. Software prepares forms, requests, and status tracking. L1 performs disconnected facts and repair. L2 performs only the D-021 person-facing act. The named external endpoint performs its own coverage, authorization, fill, delivery, transportation, or assistance decision.

Shared minutes. Clean 0. Shared M34/M35 L1 0 / 12 / 22: ordinary verify source/endpoint 2, administrative contact/repair 8, record/return 2. The illustrative complex total 30 is L1 22 plus separately triggered L2 8, not 30 minutes for each role. Record actual combined performer time once; do not add M34 again.

Completion/failure/return. Complete only with the external source-native result and the beneficiary's resulting choice where needed. A submission, promise, or “in process” response remains pending. Return supply facts to M28/M31, an unresolved barrier to ongoing follow-through, and any clinical alternative to M36.

M36. Decide a clinical alternative for an access problem#

When. M35 establishes that the regimen cannot be obtained as ordered and the remaining question is whether substitution, dose, schedule, route, formulation, or treatment should change. A denial or shortage alone does not authorize the outcome.

Purpose/value and required facts. Obtain the beneficiary-location-authorized prescribing decision without chart hunting. The packet includes the current regimen/order and indication, barrier and external response, formulary or supply facts without recommendation, prior proposal/agreement/order history, beneficiary preference, possession/reported use, safety facts, location, relevant providers, and unknowns.

Procedure.

1. Software assembles the focused packet and states the exact question; it does not rank clinical alternatives.
2. The authorized prescriber records no change, an alternative proposal, a current outside order, a safeguard within authority, or inability to decide pending named evidence.
3. A new GUIDE recommendation returns to M19–M26 for proposal, separate sharing/agreement manifests, beneficiary choice, and lawful order. Preserve an outside prescriber's route.
4. Keep access, order, pharmacy execution, possession, instruction, and monitoring separately open. A decision alone does not prove acquisition or use.

Automation and human work. L0 prepares; L1/L2 do not select or bless an alternative. The exact prescriber performs the protected act. A generic RN is not the clinical-alternative decision maker. O-028 governs the approved performer; unresolved authority is a design blocker, while immediate safety work proceeds separately.

Shared minutes. Low 5: review focused packet 2, decide/document 3. Ordinary 15: review 4, compare clinically permissible paths 7, document monitoring/return 4. Complex 30: multi-source/multi-provider judgment 18, beneficiary clinical discussion 7, document safeguards/return 5. Reuse the M17/M18 treatment-decision episode when it is the same decision; do not book M36 again.

Completion/failure/return. Complete with an attributable prescriber disposition, rationale, current instruction or no-safe-new-instruction statement, monitoring, and successor route. Missing authority/evidence produces a truthful blocked/incomplete result, never an improvised alternative.

M37. Receive a possible medication safety concern#

When. A person reports possible overdose, wrong medication/dose, extra dose, missed critical therapy, acute symptom, fall, confusion, sedation, allergic-type reaction, administration error, self-change, or urgent-advice request. CMS supports human access; this intake/routing is Proxi design, not a CMS clinical protocol.

Purpose/value and required facts. Preserve enough source-faithful information to connect the person without nonclinical triage or treatment advice. Obtain identity, callback, current physical location, caller/participant role, medication or substance as stated, what was reportedly taken or omitted if known, last known dose when safely obtainable, symptoms/event, onset/timing, actions already taken, and current connection status. Do not delay immediate emergency connection to perfect the packet.

Procedure.

1. The first human responder keeps the caller engaged where possible, captures exact words, and avoids causality, severity, urgency, or treatment conclusions.
2. An approved deterministic immediate-connect fact or a caller-reported active emergency invokes the configured emergency route immediately. Otherwise use only the approved clinical route; unapproved destinations/SLA/backup remain blocked under O-004/O-032/O-054. Missing Proxi packet-release authority holds the packet, not the caller's use of an already approved generally available emergency route. If no route is approved, that branch is not operational; staff do not select a destination ad hoc.
3. Philippine nurses acting as L1 provide nonclinical first answer and connection only. L2 does the same when the concern arises during navigation; neither gives start/stop/hold/repeat/crush/split/substitute advice.
4. Open M38 and retain failed attempts as active. Preserve separately any reconciliation, access, or monitoring obligation.

Automation and human work. Software presents approved prompts, preserves the report, and initiates configured connections. It does not triage. No continuous clinical or Puerto Rico shift is inferred from D-026.

Shared minutes. Low 3: identity/location/callback 1, exact concern 1, connect/record 1. Ordinary 7: capture 3, connection 2, record/handoff 2. Complex 12: keep engaged/capture 5, multi-attempt configured connection 4, record 3. Reuse M06 and 24/7 intake minutes once.

Completion/failure/return. M37 completes with the attributable report and a selected configured route; it does not prove clinical acceptance or disposition. Failed connection stays active in M38. Immediate connection proceeds despite incomplete routine evidence.

M38. Complete the authorized clinical safety handoff#

When. M37 has a possible safety concern requiring a configured location-authorized clinical, emergency, poison-control, pharmacy, behavioral/safeguarding, or exact outside route. The destination must match the act; no generic RN gateway is created.

Purpose/value and required facts. Obtain a professional or emergency response while keeping connection and disposition distinct. The packet includes the M37 report, location/callback, authorized regimen and separate reported use, allergies/reactions, relevant sources/unknowns, actions taken, route/authority, attempts, and any clinician-authored safeguard.

Procedure.

1. L1 or L2 helps the caller reach the configured receiver and confirms receiver, authority, time, and acceptance. Any Proxi-sent person-specific packet requires the approved exact release route; staff do not invent disclosure authority. Emergency connection is not postponed for packet completion or routine packet release.
2. Record connection accepted, connection pending, or connection failed. Acceptance completes only the transfer milestone; it is not the professional disposition.
3. The receiving L3 RN, behavioral clinician, L4 prescriber, or named external endpoint performs only the act within actual location, license, scope, and route, then returns the attributable disposition and permitted instruction when available.
4. Record the returned disposition separately and open exact treatment, reconciliation, communication, order, access, monitoring, or follow-up successors. No medication causality is inferred.

Automation and human work. Software prepares and tracks; transmission occurs only through the approved exact release route. L1/L2 connect without triage. The actual professional performs judgment. Exact destination, response time, retry, backup, and failed-connection behavior remain design-blocked where O-004/O-032/O-054 is unsettled; staff do not invent them.

Shared minutes. Nonclinical connection is the same M37 band, not additional. Professional low 5: receive/review 2, disposition 2, return 1. Ordinary 15: focused assessment 8, disposition 4, return 3. Complex 30+: assessment/coordination 18+, disposition/safeguards 7, return/successors 5. Count the same professional event once across Medication, 24/7, transition, or Ongoing evidence.

Completion/failure/return. Handoff completes only on accepted transfer; safety-result completion requires the returned professional disposition or a truthful pending/unavailable state with approved safeguards. Never close reconciliation or monitoring from connection alone. Approved new-result medication release remains governed by O-030.

Prescribing-clinician reconciliation checklist#

The prescribing-authority clinician considers, as applicable to the person and medication:

• the indication, current clinical goal, expected benefit, and beneficiary preference;
• exact dose, route, formulation, schedule, duration, PRN conditions, and transition phase;
• therapeutic duplication, intended overlap, interaction, contraindication, and allergy/reaction information;
• age, renal, hepatic, laboratory, vital-sign, diagnostic, or other clinical information required by an approved clinical rule, including whether the information is current and valid;
• symptoms, adverse-effect concerns, falls, cognition, function, behavior, swallowing, device use, and ability to execute the regimen;
• differences between orders, supply, possession, administration, and reported use;
• access, affordability, coverage, shortage, packaging, transportation, caregiver, and facility constraints;
• prescriber and condition ownership, co-management, and the provider whose agreement is required for a GUIDE-originated proposal;
• necessary patient/caregiver education, schedule support, and monitoring; and
• whether each discrepancy is intentional, resolved, still unknown, or requires another professional's action.

A deterministic high-risk, interaction, duplication, dose, or monitoring match creates a clinician-review condition only. It does not create an automatic risk conclusion, recommendation, or medication change. The current CMS DAE performance measure is not an individual deprescribing rule.

GUIDE-originated medication-change procedure#

1. The authorized Participant APN, PA, or physician determines that a medication start, stop, dose, schedule, or other change is clinically advisable and records the exact proposal, rationale, effective timing, and monitoring plan.
2. Identify separately every PCP or specialist to whom the recommendation must be shared and the relevant provider whose agreement is required before the beneficiary changes medication.
3. Prepare the exact proposal for authorized release. Software applies the accepted O-030 rule and, for a D-033 unchanged US-clinician-approved recommendation to the selected authorized PCP/specialist, sends automatically without another per-packet human OK. Any genuinely required individual review occurs first; D-031 Philippine L1 remains the paid manual courier when automation is unavailable.
4. Agreement requires an authenticated response from the relevant provider acting within scope and responding to that exact current proposal. Delivery, elapsed time, silence, office-staff acknowledgment, a response to an old proposal, or partial agreement is not agreement.
5. A modified response creates a new proposal. A declined, missing, stale, wrong-scope, unauthenticated, or revoked response leaves the proposed change inactive while the current regimen remains the operative reference pending authorized disposition.
6. The proposal may be discussed as a proposal, but staff must not present it as active instructions while required agreement remains outstanding.
7. After required provider agreement is authenticated for the exact proposal, the authorized prescriber may issue the lawful prescription or stop order according to clinical policy. Outside-order and emergency pathways remain separate.
8. Before a non-emergency change is implemented or communicated as active instructions, explain the change and record the beneficiary's or decision-specific authorized representative's informed choice. A capable beneficiary's refusal remains separate from the clinical recommendation, lawful order, reported implementation, and caregiver disagreement.
9. Do not release start, stop, hold, or change instructions until the required agreement is complete, a lawful current order exists, and the beneficiary or authorized representative has chosen to proceed, except under an approved emergency pathway.

Outside order, recommendation, and self-change procedure#

• Authenticated external order already issued or effective: preserve it as an outside clinical event, verify source and authority, determine its current applicability, and reconcile it with the current regimen. Do not force it through the GUIDE-originated proposal route merely because GUIDE received it.
• External recommendation without an order: preserve and route it for clinical adoption, rejection, or clarification. It is not active instructions.
• Administrative or ambiguous message: verify the source and exact content; office staff, a fax cover sheet, or an unsigned excerpt cannot create a medication order or agreement.
• Beneficiary self-change or refusal: record actual reported use, reason, symptoms, and decision authority; invoke reconciliation and safety review as applicable. Never treat the action as retrospective authorization.

Order, pharmacy, possession, and implementation procedure#

Confirm separately, as applicable:

1. lawful order or cancellation authored by the authorized prescriber;
2. successful transmission to the verified pharmacy or supplier;
3. pharmacy technical acceptance, rejection, or request for clarification;
4. clinical clarification or substitution decision by the authorized professional;
5. preparation, partial fill, trial fill, emergency supply, transfer, backorder, return-to-stock, or cancellation status;
6. dispensing or handoff to the beneficiary, caregiver, courier, or facility;
7. apparent household or facility possession and accessibility;
8. placement in packaging, pill organizer, reminder, MAR, or administration workflow;
9. beneficiary or caregiver report of starting, stopping, changing, delaying, or refusing; and
10. actual administration evidence when available.

For a stopped or cancelled medication, determine whether previously supplied medication remains possessed, accessible, placed in a pill organizer, administered by a facility, or reportedly taken. L2 may gather facts and provide only approved practical support; disposal, replacement, or clinical instructions require the appropriate authorized source.

Accessible instruction and teach-back procedure#

The clinician-approved instruction must distinguish what continues, starts, stops, changes, remains on hold, or remains uncertain and must include, as applicable, dose, route, timing, PRN or conditional directions, effective date, purpose, monitoring, approved missed-dose instruction, and what to do if a problem occurs.

L2 or another approved care-team member asks the beneficiary or authorized caregiver to explain in their own words:

• which medications continue, start, stop, change, or remain on hold;
• how much, how, and when each applicable item is used;
• any PRN condition, maximum, taper, alternating schedule, or conditional hold;
• which existing supply or packaging is affected;
• what monitoring or follow-up is expected;
• what warning signs and contact actions the clinician approved; and
• who will help and how the schedule support works.

Correct misunderstandings and repeat teach-back. Asking “Do you understand?” is not evidence of comprehension. If understanding cannot be demonstrated, do not document comprehension or automatically infer incapacity. With the beneficiary, identify an authorized support person or another practical aid and return unresolved safety, capacity, swallowing, device, or administration concerns to the appropriate clinician.

Schedule supports are built only from the current authorized regimen. A taper, cross-titration, alternating schedule, PRN maximum, multiple strength, or conditional hold must not be flattened into a static reminder.

Monitoring procedure#

For every medication or change requiring follow-up, the prescribing clinician defines:

• what will be monitored, including symptoms, function, falls, behavior, actual use, access, vital signs, laboratory results, other testing, or a clinical visit as applicable;
• who obtains each input and by what permitted route;
• who is clinically responsible for reviewing the result;
• clinically appropriate timing and what finding requires earlier contact;
• what action or communication is expected after review; and
• how missed, unavailable, stale, conflicting, or late monitoring is escalated.

L0/L1 may remind, retrieve, and track. L2 may support completion and report observations. Only the authorized clinician interprets the result and decides medication action. A reminder sent or test completed does not prove clinical review.

Transition-specific medication procedure#

For transitions, compare all applicable source classes rather than selecting the discharge list by recency:

1. regimen and reported use before the transition;
2. medication actually administered in the facility or emergency setting;
3. discharge or transfer orders and instructions;
4. prescriptions and cancellations actually transmitted;
5. pharmacy responses and supply events;
6. medication physically present at home or the receiving facility;
7. what the beneficiary, caregiver, or facility is currently doing; and
8. pending tests, results, monitoring, and responsibility for follow-up.

The completed transition medication outcome must return to the Care Coordination transition episode. Missing discharge information, a newly issued outside order, rapid readmission, or late corrected record remains visible and creates the applicable follow-up; it does not silently overwrite the reconciled regimen.

Timing and escalation#

Objective completion criteria#

Complete only the milestone supported by the evidence. Do not withhold a finished professional result because a later action is pending, and do not claim the entire medication episode finished because a professional result exists.

Example: a clinician completes a no-change review today and orders a lab next month. Today's M14–M15 result is complete; that monitoring obligation is not yet due. If the clinician needs the missing lab to decide today's regimen, M15 instead records an incomplete result and the safe current course or inability to release a new instruction. A refill claim, pickup report or later lab cannot select either outcome automatically.

Parent episode closure requires the applicable obligation set and a truthful success, refusal, withdrawal or unresolved disposition under O-026; it does not require every possible task for every beneficiary. GUIDE service qualification is separately evaluated from the actual authorized service and current CMS/Agreement evidence under O-034. Software surveillance, L1 pursuit, an alert, a task assignment or infrastructure availability alone creates no service credit. No new service-gate policy is approved here.

Cross-pillar medication feeds#

This SOP participates in cross-pillar episodes under 25_GUIDE_Eight_Pillar_Service_Integration.md. Medication Management receives service attribution only for an attributable prescribing-authority reconciliation or decision, a truthful incomplete result, an executed medication access or change step, or an authorized monitoring result with the next owner identified. Opening a medication case, ingesting a list, sending a transfer, issuing an order, or obtaining pharmacy acceptance does not silently stand in for the later result.

Assessment opens the required reconciliation occasion and supplies source material. Ongoing Monitoring asks only the bounded current-use or problem question unless a real trigger exists, then follows the exact access, use, or monitoring return without performing reconciliation. During a transition, the medication work remains incomplete until the route-specific authorized clinician produces a complete-no-change, complete-with-change, or truthful incomplete result and any safe current instruction or inability to release a new instruction is explicit under the still-open O-028 authority decision.

What this pillar provides as a service#

Proxi can perform or accelerate intake, retrieval, literal comparison, preparation, permitted communication, tracking, reminders and faithful record updates. A direct beneficiary/caregiver report is not automatically a Proxi-paid human interview. Prescribing-authority reconciliation, actual prescribing/deprescribing judgment, lawful order authorship, applicable treating-provider agreement and protected safety/monitoring acts remain with their exact authorized professionals. The §7.5 navigator information is a real navigator service. Other L1/L2 work occurs only for its actual administrative or D-021 human need; clinical authorship, faithful delivery, person choice and whole-episode completion do not create blanket extra reviews.