Status: Public-source working task breakdown
Date: 2026-10-03
Scope: GUIDE program-operating work outside the eight in-scope care-service tables. GUIDE respite-service delivery is excluded.
Controlling-source limitation#
This is a literal operating-work inventory grounded in public CMS materials and reviewed on 2026-10-03. It is not yet the final contractual inventory. Routine preparation and administration are distinct from the actual assessment, clinical judgment, patient/caregiver choice, business approval, attestation and submission they support.
The executed PY 2026 Amended and Restated GUIDE Participation Agreement, its contractual Appendix D, the current GUIDE Connect instructions, and the live PAAF and portal manuals remain controlling missing sources. They must be compared with every row before the row is treated as final policy. The Appendix D in the public Payment Methodology Paper is the aligned-patient notice template; it is not the Participation Agreement's contractual Appendix D.
The public sources used here are:
- GUIDE Payment Methodology Paper v3.0, effective 2026-06-01 (PMP)
- GUIDE Performance Measurement Manual v3.0, published 2026-05-18 (PMM)
- Current GUIDE Frequently Asked Questions, modified 2026-09-25 (FAQ)
- Public GUIDE Request for Applications (RFA)
- Current GUIDE model page
“Current public GUIDE basis” names the source and locator that supports the row. A Necessary delivery work row is an operating step needed to produce or prove a required result, not wording CMS expressly prescribed. Beyond the public GUIDE minimum means outside that GUIDE minimum, not always optional under other programs: PO-128's QPP/MIPS obligation remains independently mandatory when applicable and must not be confused with a furnished GUIDE service.
Monthly DCMP service floor#
The monthly payment floor is one actually furnished non-respite GUIDE care-delivery service for the aligned patient, not one service from every domain. CMS publishes no minimum minutes and no minimum number of distinct service lines. “Furnished” is the relevant concept: an ongoing monitoring contact, caregiver-support interaction, medication-management action, transition action, or other qualifying care-delivery service may be complete for billing even though the beneficiary's broader care episode remains open.
The one-service floor and the tier contact requirement are separate checks:
| Current tier | Required contact cadence | Smallest claim-ready month under the public rule | Review |
|---|---|---|---|
| Low-complexity dyad | At least quarterly | One actual non-respite service. In an off-contact month, it may be a non-contact service if the quarterly cadence remains current. | |
| Moderate-complexity dyad | At least monthly | One substantive required touchpoint may be the qualifying service; no second service line is required. | |
| High-complexity dyad | At least monthly | One substantive required touchpoint may be the qualifying service. | |
| Low-complexity individual | At least monthly | One substantive required touchpoint may be the qualifying service. | |
| Moderate-to-high-complexity individual | At least twice monthly | Two distinct required touchpoints, but they may remain within the same service domain and still produce only one DCMP claim. | |
| RCC | At least bimonthly, using CMS's current wording | One actual non-respite service. In an off-contact month, it may be a non-contact service if the bimonthly cadence remains current. Contractual Appendix D must confirm the exact RCC cadence and qualifying-service details. |
A required touchpoint may be with the beneficiary and/or caregiver and need not be a clinical encounter. A caregiver-facing GUIDE service can support the aligned patient's month when it is actually furnished, attributable to that patient, and documented through a permitted provider route. One interaction may evidence several service obligations while its human minutes are counted once and the patient-month still produces only one DCMP. A passing mention, failed outreach, passive course availability, unused 24/7 line, or infrastructure maintenance does not qualify.
If a required touchpoint is overdue, another service does not cure the cadence failure: CMS says the DCMP may not be billed until the required touchpoint is completed. One no-service month receives no DCMP but does not immediately end alignment. Eight consecutive months without either a DCMP or GUIDE Respite Services claim is a current CMS claims-based unalignment condition. The public source does not establish whether a late touchpoint retroactively cures an earlier otherwise-supported month; that interpretation remains open under O-047 pending the executed Participation Agreement or written CMS guidance.
Low-burden service-selection rule#
Use the tier-required substantive navigator contact as the monthly service anchor whenever one is due. Combine all currently applicable person-facing work into that interaction rather than scheduling separate medication, care-plan, referral, and caregiver calls. If a naturally occurring inbound navigator interaction independently satisfies the same contact requirements, use it and cancel the redundant planned contact.
Do not start with a billing category or target duration. Before proactive outreach, state the person-specific reason the conversation is appropriate now, the service the navigator will furnish, the useful result the beneficiary or caregiver should receive, and why their participation is needed. Cadence determines when a required contact is due; the person's need, choice, question, current goal/action, open promise, or ongoing-support purpose determines the agenda. Classify the service for billing only after it was actually furnished. A topic not asked about remains not asked and cannot be credited as a no-change result.
In a low-dyad or RCC off-contact month, look first for work already required by the person's care: an active referral or provider response, transition recovery, requested or triggered medication work, an open care-plan action, accepted caregiver support, or another real patient-specific service. Do not delay care to spread work across months, split one natural episode to create several claims, or contact a person merely because the billing calendar is empty. If no actual service is furnished, the correct result is no DCMP claim for that month.
A no-change result supports a month only when it is the outcome of real service work. Beneficiary-confirmed plan fit inside a substantive navigator contact is plan maintenance; an actual prescribing-authority reconciliation may conclude complete without change. An AI no-delta result, unchanged fields, a reminder, a failed attempt, passive monitoring, administrative pursuit alone, or cosmetic documentation is not a furnished service. The complete operating design and tier schedule are in 23_GUIDE_Low_Burden_Monthly_Service_Plan.md.
How the program work is performed#
Who does the work and who pays for it#
Proxi supplies or contracts the in-scope program, navigation and clinical work under D-012. A GUIDE Participant's institutional accountability does not make routine Proxi labor free customer labor. Retain a separate Participant act only when its exact nondelegable or retained requirement is known; the unresolved act remains visibly unassigned under O-PA-001, not performed by an invented program/compliance owner.
- Software first: retrieve permitted sources, validate identifiers and dates, compare approved facts/rules, schedule, calculate deadlines, assemble current forms, retain receipts and produce the exact correction list. AI extracts or drafts; it does not attest, determine eligibility or make clinical/business decisions.
- Philippine L1: obtain a missing administrative fact or use a manual channel. A CMS-approved data custodian or portal user is a permission held by an authorized existing employee, not another job. Offshore assignment and access require actual approval; do not infer them from this proposed staffing model.
- Puerto Rico L2: perform a required human GUIDE contact, requested explanation, neutral direct preference conversation, support or transition assistance. Routine scheduling, clear facts and direct accessible choices do not require another navigator blessing.
- Exact U.S. clinician: supply only the clinical examination, staging interpretation, diagnosis/attestation, clinical correction or other protected judgment actually needed. Reuse the current attributable product; do not charge its clinical work again when copying it into a PAAF, report or handoff.
- Corporate work: Billing and Revenue Cycle handles financial exceptions; HR and Workforce handles personnel/credential files; the System Administrator handles approved access/configuration; Software Engineering handles defects. Same-lane leads handle recovery. Legal Counsel answers a bounded uncovered legal question, not every clean transaction.
- Administrative Manager: gives the final Proxi business approval for new partner contracts or changed service/coverage commitments under
D-027. This does not itself confer signing, CMS approval, reporting-attestation, clinical or legal authority.
The public PMP expressly permits PAAF submission through HDR or approved FHIR endpoints. Automated preparation and an approved connected submission may therefore have zero incremental Proxi human time once required clinical products, choices, attestations and release conditions are complete. A manual portal fallback uses the approved employee's narrow submission act. The current interface, identity, automatic-release and offshore permissions remain O-058/O-PA-001; this draft does not activate them.
Current V1 outbound-PHI release still follows D-007: a proposed automatic interface is not permission to bypass the required human release. Where a class retains that act, Proxi pays the approved employee's actual narrow contribution; an unknown performer or permission is not assumed to be free customer labor. An automation band describes the work mechanism, not guaranteed zero human cost.
Navigator training is workforce work, not caregiver training or patient service credit. CMS's public baseline is at least 20 initial hours, including at least 10 didactic and 10 live experiential hours, plus at least two additional annual hours. Web-based instruction can remove an instructor touch, not the employed learner's time. At Leon's $22/hour L2 rate, the minimum learner-time floor is $440 for 20 initial hours and $44 for two annual hours, before additional instruction, assessment/remediation, course fees or other overhead. Share actual cohort-instructor time once; count every employee's actual learning separately. No fixed caregiver-course duration or caregiver quiz is inferred from this navigator requirement.
The five clinical-product-dependent rows are PO-022, PO-026, PO-045, PO-051 and PO-106. They consume or produce qualified staging/diagnosis/attestation products—not five extra clinical reviews of every form. Other clinical-trigger rows distinguish a new patient-specific question, an actual source correction and portfolio clinical-content/intervention work; routine reuse has zero new clinician minutes. Programme/hiring/reporting/training time is not a beneficiary clinical encounter.
RCC move — determine the exact residence-change route#
Use this procedure with PO-010, PO-077–PO-082, PO-105, PO-109 and PO-115. It concerns an already aligned patient who moves, not permission to align a new RCC resident without prerequisites.
- Record the actual facility and unit/bed, whether the move is temporary or permanent, move date and date the Participant became aware. A campus name does not distinguish an RCC from a Memory Care Unit or nursing-home bed.
- Obtain two separate dated facts for this Participant and RCC: current CMS RCC-Partner approval and a fully executed compliant Partner Organization Arrangement. Unknown, expired or conflicting facts are not converted to false or true by AI.
- Apply the following public-source route. The PMP §2.12 60-day trigger uses AND, not OR.
| CMS RCC approval | Compliant arrangement | Applicable route for the already aligned mover | Review |
|---|---|---|---|
| Yes | Yes | Ordinary eligible-RCC route, subject to all other eligibility, service, PAAF and billing requirements. No new 60-day exception is needed. | |
| No | No | The stated §2.12 60-day transition begins when the Participant becomes aware of the move. The Participant may continue GUIDE services and billing during that applicable period while seeking approval and a compliant arrangement. | |
| Yes | No | An ordinary RCC prerequisite is missing, but the public AND trigger is not met. Do not invent a 60-day grace period or treat the case as compliant; obtain the executed Agreement or written CMS disposition under O-024/O-PA-001. | |
| No | Yes | The opposite prerequisite is missing and the public AND trigger is not met. The same exact interpretation hold applies; neither the contract nor the move approves the RCC. | |
| Unknown, expired or conflicting | Any, or unknown | Pursue and verify the affected fact. Hold only the unsupported RCC eligibility/service/billing disposition; continue independently authorized support and urgent safety work. Do not start or reset a grace period from uncertainty. |
- During a valid No/No period, software calendars the awareness-based deadline and tracks each prerequisite separately. Philippine L1 pursues the missing records; the Administrative Manager approves the business commitment; Legal Counsel enters only for an uncovered legal issue; the approved submitter pursues CMS approval. The unapproved RCC may not itself furnish services as an approved Partner under §1.4.2 merely because the Participant has transition permission.
- If both prerequisites become effective, verify their dates and the actual RCC/Partner ID, complete the applicable residence-change PAAF work and return to the ordinary RCC route. If either remains missing, do not declare normal eligibility from a signed contract alone. The end-of-period interpretation when approval alone remains pending requires
O-024/O-PA-001. - If the compliant arrangement cannot be established within the stated 60 days, §2.12 requires care-transition coordination, transition planning assistance and an unalignment PAAF. Puerto Rico L2 performs the actual person-facing transition act, the approved data custodian performs the CMS submission and Billing applies CMS's actual result/date. Clinical staff enter only for an independent clinical transition need.
- Keep the 15-day Memory Care Unit move route separate. It requires transition/planning and unalignment; it is not an RCC contracting opportunity. Its special final-claim deadline is 30 days after effective unalignment, not a new service window.
Completion: verified source facts and awareness date, the applicable approved disposition, actual approval/arrangement or transition products, required PAAF and CMS response, correct billing dates and separately owned open care needs. An application, signed draft, reminder, attempted transfer or pending CMS response is not the missing approval or completed transition. The current FAQ states ordinary pre-delivery prerequisites broadly; reconcile it with the PMP's explicit transition permission and the executed Agreement before using an unresolved case in the field.
Minimum cases: all four known approval/arrangement combinations; unknown status; expired agreement; mixed campus/unit; delayed discovery; corrected awareness date; late-arriving approval; arrangement achieved but CMS approval pending at day 60; successful ordinary-route return; failed transition handoff; and an independent clinical/safety need during a status hold.
Literal program-operations task table#
| Task | What the task entails | Current public GUIDE basis | What Proxi can do | Person required? | Person or role | Review |
|---|---|---|---|---|---|---|
| PO-001 — Open a potential-patient intake | Open one pre-alignment intake from a referral, inquiry, or internal lead; preserve the source, contact route, stated reason, duplicate candidates, and missing facts without calling the person aligned. | Necessary intake work supporting FAQ Q6 and PMP §§2.2-2.4. | Capture the intake, prefill known facts, detect duplicates, and produce a missing-information list. | No on a clean digital intake; yes when a person calls, a source must be pursued, or intake ownership remains disputed. | Software opens and de-duplicates; Philippine L1 answers or pursues missing administrative facts; Puerto Rico L2 enters only when an established beneficiary relationship or requested human explanation is already in scope. | |
| PO-002 — Confirm the address is in the participant service area | Compare the verified current residence ZIP/date with the Participant's current CMS service-area list and Proxi's approved delivery capability. A CMS-added ZIP does not prove Proxi can furnish required local services; obtain an actual coverage commitment when needed, not a routine manager review. | PMP §1.4.3; FAQ Q7. | Compare the address with the current approved ZIP list and flag mismatches or incomplete addresses. | No for an authoritative exact match; yes only to obtain or correct a missing/conflicting address or to approve a new service-area commitment. | Software performs the match; Philippine L1 obtains address evidence; the Administrative Manager approves a new Proxi coverage commitment, not the routine case result. | |
| PO-003 — Confirm enrollment in Medicare Parts A and B | Retrieve an authorized eligibility response for the relevant date and verify active Medicare Parts A and B, preserving source, transaction time, and conflicting records. | PMP §2.4; FAQ Q4. | Retrieve or ingest the authorized eligibility response, compare dates, and flag absent or conflicting coverage. | No for a clear authoritative response; yes only for failed access or conflicting evidence. | Software retrieves and compares; Philippine L1 pursues a missing administrative response; System Administrator restores approved access and Software Engineering fixes a confirmed implementation defect. | |
| PO-004 — Confirm Medicare is the primary payer | Read the authoritative payer-order result for the relevant date and distinguish Medicare-primary from permitted secondary coverage or an unresolved payer conflict. | PMP §2.4; FAQ Q4. | Compare available payer-order data and surface uncertainty for review. | No for a clear result; yes for manual payer evidence pursuit or a genuine payment-order dispute. | Software compares payer-order data; Philippine L1 pursues missing evidence; Billing and Revenue Cycle resolves the bounded payment-order exception. | |
| PO-005 — Confirm the patient is not enrolled in Medicare Advantage, a Special Needs Plan, or PACE | Check current and future-effective MA, SNP, and PACE enrollment from an authorized source and keep current ineligibility separate from a pending change. | PMP §2.4; FAQ Q4. | Read authorized coverage data, compare effective dates, and flag disqualifying enrollment. | No for a clear authoritative result; yes only for failed retrieval or conflicting enrollment dates. | Software performs the dated match; Philippine L1 pursues missing administrative evidence; Billing and Revenue Cycle handles an actual payer-status dispute. | |
| PO-006 — Confirm the patient has not elected the Medicare hospice benefit | Verify current hospice-election status and effective date from authorized eligibility or claims evidence; preserve any contradiction with the care record as a separate unresolved fact. | PMP §2.4; FAQ Q4. | Compare authorized claims or eligibility data with the record and flag a possible election. | No for a clear authoritative status; yes for missing/conflicting administrative evidence and separately for any resulting clinical transition need. | Software compares dated sources; Philippine L1 pursues the status; Billing and Revenue Cycle resolves a payment-status exception; the existing authorized U.S. clinician enters only for a distinct clinical transition question. | |
| PO-007 — Confirm the patient is not aligned to another GUIDE participant | Match the person to the current BAR or other authorized CMS alignment result and identify active, ending, absent, or unresolved prior alignment. | PMP §§2.4 and 2.14; FAQ Q4-Q5. | Compare the patient with the current Beneficiary Alignment Report and flag a current or ending alignment. | No for a matched CMS result; yes for missing/mismatched records or the separate transfer conversation. | Software imports and matches; Philippine L1 in approved data-custodian capacity pursues a missing report; Puerto Rico L2 performs only the triggered transfer relationship work. | |
| PO-008 — Collect the facts needed to classify the residence | Collect the actual address, facility, unit or bed type, move dates, permanence, and source for the current residence without inferring the category from the facility name. | PMP §§2.4 and 2.12; FAQ Q4 and Q8. | Ask structured questions, normalize facility names and addresses, and flag ambiguous setting descriptions. | No for complete direct or authoritative facts; yes for missing facility facts, conflicting accounts, or a requested human clarification. | Software conducts structured intake; Philippine L1 verifies administrative facility facts; Puerto Rico L2 clarifies an unresolved beneficiary/caregiver living-arrangement fact; Healthcare Legal Counsel enters only for a complete uncovered classification-authority question. | |
| PO-009 — Apply the PY 2026 eligible-residence rule | Apply the approved PY 2026 residence rule to canonical setting, RCC approval, arrangement, service-area, and effective-date facts and return the exact failed or unresolved predicate without claiming CMS alignment. | PMP §2.4; FAQ Q4 and Q8. | Compare the residence facts with the current public rule and approved RCC list, then explain what fact failed without making the CMS alignment decision. | No when every fact fits an approved rule; yes only for a verified fact pattern the approved rule does not cover or for a required attestation. | Software applies the rule; Philippine L1 corrects missing administrative evidence; the actual attestation performer remains a separate exact act under PO-027/O-PA-001; Healthcare Legal Counsel answers only a genuine uncovered legal question. | |
| PO-010 — Verify RCC approval and arrangement prerequisites during intake | For new intake, verify both current CMS RCC approval and an effective compliant arrangement, plus the correct Partner ID. If either is absent, do not start the already-aligned-mover 60-day route; hold dependent initial RCC alignment/delivery while pursuing the missing prerequisite. Keep unknown different from confirmed absent. | PMP §§2.4 and 2.8.1; FAQ Q8 and Q14. | Compare the RCC with the current roster and agreement dates and identify any missing approval, arrangement, or Partner ID. | No for clean authoritative matches; yes to obtain missing approval/arrangement evidence or cure a failed prerequisite. | Software performs the three-way match; Philippine L1 pursues records; Administrative Manager and Healthcare Legal Counsel handle only actual arrangement business/legal work; CMS and the RCC supply their own approval/contract acts. | |
| PO-011 — Identify whether dementia confirmation is still needed | Retrieve and source-date diagnosis evidence, distinguish diagnosis, MCI, suspected dementia, and absent evidence, and send only the prepared sufficiency/attestation question to the roster clinician. | PMP §§2.4-2.6; FAQ Q4. | Retrieve and organize diagnosis records, identify the source practitioner and date, preserve gaps/conflicts, and prepare the exact attestation question without converting missing or uncertain evidence into an eligibility conclusion. | No for retrieval and gap identification; yes when the evidence must be clinically interpreted or an attestation decision is required. | Software and Philippine L1 assemble/pursue records; the beneficiary-location-authorized dementia-proficient L4 roster clinician performs the narrow clinical sufficiency or attestation judgment. | |
| PO-012 — Explain GUIDE services and exclusive GUIDE care-delivery alignment | Explain the actual GUIDE services, voluntariness and one-Participant care-delivery relationship through the approved accessible mode; document the discussion, questions, understanding and attributable response before consent/assessment. Do not promise CMS alignment. | PMP §2.5 and Appendix G; FAQ Q5. | Prepare and present approved plain-language material, support language access, and record the topics covered. | The beneficiary and/or caregiver permitted by the controlling GUIDE rule supplies the voluntary choice. Proxi human facilitation is mode-dependent: required by the approved process, requested, or needed for comprehension/authority/accessibility. No public blanket live-staff mandate is inferred. | Software prepares approved accessible content and retains the discussion/response; Puerto Rico L2 performs the required/requested nonclinical facilitation. Caregiver participation, permitted GUIDE consent and decision-specific representative authority remain separate. O-011/O-037/O-041/O-PA-001 must approve the actual mode; a clinical capacity or uncovered legal question uses its own authorized route. | |
| PO-013 — Explain voluntariness, freedom of choice, and the right to stop | Explain that participation is voluntary, other Medicare provider choice remains available and GUIDE may be stopped; preserve the person's questions and choice without pressure. Reuse the same discussion as PO-012/015 rather than arranging another contact. | PMP Appendix G; FAQ Q5-Q6. | Deliver approved wording, check understanding, and document questions without pressuring the decision. | The beneficiary and/or caregiver permitted by the controlling GUIDE rule supplies the voluntary choice. Proxi human facilitation is mode-dependent: required by the approved process, requested, or needed for comprehension/authority/accessibility. No public blanket live-staff mandate is inferred. | Software prepares approved accessible content and retains the discussion/response; Puerto Rico L2 performs the required/requested nonclinical facilitation. Caregiver participation, permitted GUIDE consent and decision-specific representative authority remain separate. O-011/O-037/O-041/O-PA-001 must approve the actual mode; a clinical capacity or uncovered legal question uses its own authorized route. | |
| PO-014 — Identify whose consent can be documented | Verify speaker identity, caregiver participation and any decision-specific representative authority, dates, restrictions and conflicts. If caregiver assent conflicts with beneficiary refusal, hold the dependent GUIDE assessment/PAAF and preserve both statements; do not substitute the caregiver response. A dementia diagnosis alone does not establish incapacity. Capacity or legal-authority uncertainty uses the exact qualified route under O-011/O-037/O-PA-001. | PMP §2.5 and Appendix G; current FAQ Q5. Exact controlling details remain subject to the Participation Agreement. | Collect identity and representative documents, show missing authority evidence, and route capacity or authority questions. | No when authoritative identity and decision-specific authority records are complete; yes for relationship clarification, capacity concern, or a genuine uncovered legal question. | Software checks known records; Philippine L1 obtains documents; Puerto Rico L2 clarifies participation/relationship facts; the appropriate U.S. clinician handles decision-specific capacity within scope; Healthcare Legal Counsel handles only an uncovered legal-authority question. | |
| PO-015 — Obtain and document consent or refusal before the initial assessment | Complete the required GUIDE discussion, obtain attributable consent or refusal from the patient and/or caregiver permitted by the actual rule, and document it in the medical record before the initial assessment. Appendix G is optional. A caregiver is not automatically a legal representative; an additional witness/signature is not invented. | PMP §2.5 and Appendix G; FAQ Q5. | Prepare the record entry or optional form, check required elements and timing, and preserve the signed or otherwise documented evidence. | The beneficiary and/or caregiver permitted by the controlling GUIDE rule supplies the voluntary choice. Proxi human facilitation is mode-dependent: required by the approved process, requested, or needed for comprehension/authority/accessibility. No public blanket live-staff mandate is inferred. | Software prepares approved accessible content and retains the discussion/response; Puerto Rico L2 performs the required/requested nonclinical facilitation. Caregiver participation, permitted GUIDE consent and decision-specific representative authority remain separate. O-011/O-037/O-041/O-PA-001 must approve the actual mode; a clinical capacity or uncovered legal question uses its own authorized route. | |
| PO-016 — Stop the alignment workflow after refusal or absent consent | Hold the dependent GUIDE assessment/PAAF when consent is absent, refused or conflicting. Caregiver assent does not clear an unresolved beneficiary refusal. Preserve both statements and the recontact route; only the exact valid consent/authority resolution reopens the path. Independent authorized ordinary care and immediate safety work continue. | PMP §2.5 and Appendix G. | Hold the dependent GUIDE assessment/submission; preserve independent authorized low-cost preparation, safe ordinary care and the respectful recontact route. | No for the hold; yes only for the already required respectful communication or a later new consent discussion. | Software enforces the hold; Puerto Rico L2 handles any required person-facing explanation or later re-entry discussion. | |
| PO-017 — Schedule the initial comprehensive assessment after consent | Offer valid assessment times and permitted modalities after consent, book the selected slot, send accessible reminders, and attach the verified intake/consent packet. | PMP §2.5; FAQ Q6 and Q13. | Offer times, send reminders, assemble the pre-visit packet, and flag accessibility or caregiver-participation needs. | No for connected scheduling; yes for an unconnected office, failed booking, or unresolved accessibility/participation need; the separate assessment requires its own performers. | Software schedules; Philippine L1 performs manual scheduling; Puerto Rico L2 clarifies a preference or relationship barrier only when needed. | |
| PO-018 — Obtain the current PAAF and current completion instructions | Retrieve the current HDR PAAF template, FHIR QuestionnaireResponse specification when used, GUIDE Manual/ISP instructions, and submission-date field rules; compare them with the working build before population. | PMP §§2.1, 2.7.1, and 2.10; PMM §§1.5 and 2.2. Current GUIDE Connect and portal instructions remain controlling missing sources for this project. | Track the current approved form, compare it with the working packet, and identify changed fields before data entry. | No through a maintained authoritative interface; yes for manual portal retrieval or an unresolved instruction conflict. | Software retrieves/version-checks when connected; Philippine L1 in approved data-custodian capacity retrieves manually; System Administrator restores access; Software Engineering corrects a parser/mapping defect. | |
| PO-019 — Collect and verify patient identifiers for the PAAF | Populate legal name, MBI, date of birth, and current required identifiers from authorized sources, and hold only mismatched fields for correction. | PMP §2.7.2 and Exhibit 6. | Prefill from authorized sources, validate format, and compare identifiers across records. | No for exact authoritative matches; yes for missing or conflicting identifiers. | Software matches; Philippine L1 obtains/corrects administrative identity evidence; the beneficiary or representative supplies their own facts. | |
| PO-020 — Collect caregiver identity and status for the PAAF | Ask the current structured caregiver questions, record identity, relationship, primary-caregiver status, participation permission, and no-caregiver versus unknown distinctly. | PMP §§2.1, 2.5, and Exhibit 6; PMM §2.2. | Ask the structured questions, prefill known data, and flag ambiguous unpaid-caregiver status. | No for a clear direct accessible response; yes for failed digital access, unresolved relationship facts, or a required human clarification. | Software captures direct responses; Philippine L1 obtains missing administrative details; Puerto Rico L2 performs relationship clarification; the beneficiary/caregiver supplies the facts. | |
| PO-021 — Collect the roster clinician information for the PAAF | Populate clinician identity/NPI and match the attesting clinician to the current Practitioner Roster and relevant effective date. | PMP §2.6 and Exhibit 6. | Prefill roster data and flag an NPI or roster mismatch. | No for an exact match; yes for a roster, NPI, relationship, or effective-date mismatch. | Software matches; HR and Workforce Administration corrects credential-file facts; Philippine L1 in approved data-custodian capacity handles roster-source pursuit/manual portal work. | |
| PO-022 — Administer and interpret the approved dementia-staging tool | Use the selected current CDR or FAST instrument in the initial assessment, capture source responses, calculate only its published score and obtain the clinically valid staging interpretation from the qualified in-scope professional. Preserve the administration date as the PAAF assessment date and reuse the result once. | PMP §§2.5, 2.7.1, and 2.8. | Present the configured instrument, capture responses, calculate only the published score, and prepare the result for clinician interpretation. | Yes for the clinically valid administration/interpretation required by the assessment; no second Program Operations clinician after an accepted result exists. | The qualified beneficiary-location-authorized U.S. clinical support RN or U.S. prescribing or Part B E/M clinician performs administration/interpretation only when that instrument, task and jurisdiction permit it. Required qualification is validated under O-018/O-PA-001; no default L4-only rule is added. The separate dementia-proficient roster practitioner supplies PO-026/045 attestation; software prepares and reuses the products. | |
| PO-023 — Administer PROMIS-10 at the initial assessment | Present every current PROMIS-10 and supplemental item through an approved accessible route, capture the beneficiary's attributable responses, validate completeness, and route any configured care/safety signal separately. | PMP §2.5; PMM §§2.1-2.2. | Present the instrument, validate completion, score configured fields if allowed, and flag concerning or missing responses. | The beneficiary supplies responses; no Proxi human on a clear approved digital path; assessment staff or a clinician enters only for assistance or a triggered care question. | Software administers/scores; Puerto Rico L2 or assessment staff assists only when needed; the exact U.S. clinician receives a genuine clinical trigger. | |
| PO-024 — Administer ZBI-22 when there is an identified caregiver | When an identified primary caregiver exists, present all current ZBI-22 and supplemental items, capture direct responses or refusal, calculate the configured score, and open separate support/safety work when triggered. | PMP §§2.5 and 2.8; PMM §§2.1-2.2. | Present the instrument, validate completion, calculate the configured score, and flag high burden or safety concerns. | The caregiver supplies responses; no Proxi human on a clear approved digital path; L2 or a clinician enters only for assistance, support, or safety trigger. | Software administers/scores; Puerto Rico L2 provides relationship/support assistance; the exact U.S. clinician receives a clinical or safeguarding trigger. | |
| PO-025 — Assemble the dementia-diagnosis evidence for the attesting clinician | Retrieve source records, identify practitioner/date and assessment findings, preserve gaps/conflicts, and assemble the exact source-linked packet without treating a diagnosis code as the attestation. | PMP §2.6. | Retrieve records, extract the diagnosis source and date, and mark missing or conflicting evidence. | No for connected retrieval/assembly; yes for manual records pursuit and for the separate clinician attestation. | Software assembles; Philippine L1 pursues authorized records; the dementia-proficient L4 roster clinician consumes the packet under PO-026 rather than being charged for assembly. | |
| PO-026 — Complete the dementia diagnosis attestation | Have the dementia-proficient roster clinician review the prepared evidence, perform any clinically necessary history/examination, and sign the exact dementia attestation or record insufficiency/non-dementia. | PMP §§2.4 and 2.6; FAQ Q4. | Prepare the evidence summary and PAAF field, but never make or sign the diagnosis attestation. | Yes for every attestation occurrence. | Proxi-supplied or contracted beneficiary-location-authorized L4 clinician on the GUIDE Practitioner Roster; software prepares the statement and retains the signed result. | |
| PO-027 — Complete the eligible-residence attestation | Assemble verified address, setting, service-area, RCC approval, arrangement, and effective-date evidence and present the exact residence attestation required by the current PAAF. | PMP §§2.4 and 2.7; Exhibit 6. | Assemble address, setting type, RCC approval, and arrangement evidence and draft the attestation record. | Only if the current PAAF/Agreement requires an individual attestation or manual official release; no clinical reviewer is required. | Software prepares; the exact approved organizational signer is SOP DESIGN BLOCKED — NOT OPERATIONAL under O-PA-001 until the controlling provision and assignment are known; an approved existing employee in data-custodian capacity may transmit after the attestation is complete. | |
| PO-028 — Record residence type and RCC Partner ID | Populate the exact residence type and, when applicable, the approved RCC Partner ID from current authoritative records and cross-check address, approval, arrangement, and effective date. | PMP §2.7 and Exhibit 6. | Prefill from the approved RCC roster and detect inconsistent address, setting, or Partner ID data. | No for a clean match; yes only to correct a source mismatch. | Software matches/populates; Philippine L1 in approved data-custodian capacity pursues a correction; Administrative Manager/Healthcare Legal Counsel enter only if the underlying arrangement itself must change. | |
| PO-028A — Confirm the initial home-visit assessment is complete before PAAF submission | Match the required initial home-visit assessment record, modality, performer, date, and completion result to the current PAAF prerequisite and hold submission when evidence is absent or contradictory. | PMP §§2.1 and 2.7 and Exhibit 6; the current portal instructions remain controlling for exact fields. | Bring forward the tier rule and home-visit record, identify a missing or contradictory completion fact, and hold the PAAF for its actual owner rather than inventing the result. | No for the completion check; the assessment itself retains its already counted human performers; yes only to obtain/correct missing evidence. | Software matches the accepted assessment product; Philippine L1 pursues missing administrative evidence; the original assessment professional corrects only their own substantive record. | |
| PO-029 — Assemble the complete initial PAAF packet | Map each accepted patient, caregiver, clinician, attestation, residence, staging, PROMIS-10, ZBI-22, and current required field to the current HDR or FHIR submission payload with provenance. | PMP §§2.5-2.7 and Exhibit 6; PMM §2.2. | Map verified source data to the current PAAF and show the source for each populated field. | No for source-complete assembly; yes only for a missing source field, required signer, or manual transmission after authorizations are complete. | Software assembles; Philippine L1 pursues administrative gaps and may act in approved data-custodian capacity for manual fallback; original clinicians correct only their own clinical products. | |
| PO-030 — Check the PAAF for completeness, dates, and internal consistency | Run current conditional-field, date-order, 60-day, consent-before-assessment, staging-date, residence, attestation, and cross-field consistency checks and return a source-specific correction list. | Necessary control supporting PMP §§2.5-2.7. | Run deterministic completeness and consistency checks and produce a precise correction list. | No for the check; yes only for the source owner to correct an actual flagged fact. | Software checks; Philippine L1 fixes administrative source gaps; the original L3/L4 professional corrects only a clinical source conflict; no generic reviewer is added. | |
| PO-031 — Resolve missing or contradictory PAAF facts | Route each exact missing or contradictory field to its source owner, pursue replacement evidence, preserve the old value, and rebuild only after an attributable correction arrives. | Necessary delivery work for a valid PMP §2.7 submission. | Route each discrepancy, track its owner, and refresh the packet after an authorized correction. | No for an approved connected source correction or factual CMS follow-up; the appropriate Proxi employee acts only for manual pursuit, a genuine clinical/legal source judgment, or a required manual transmission. | Philippine L1 pursues administrative evidence; Puerto Rico L2 clarifies beneficiary/caregiver participation facts; Billing and Revenue Cycle resolves billing facts; the original authorized L3/L4 clinician corrects clinical substance; Healthcare Legal Counsel answers only an uncovered legal question. | |
| PO-032 — Submit the initial PAAF within 60 days | After every required authorization/attestation is complete, transmit the exact validated initial PAAF through approved HDR or FHIR within 60 days of the staging-assessment date and retain the CMS receipt. | PMP §2.7.1; PMM §2.2. | Prepare the upload, check the deadline, and support an authorized submission while preserving the exact submitted content. | No for an approved standing FHIR transmission; yes for a manual CMS-identity/portal submit act or failed transmission. | Software transmits on an approved connected path under O-058/O-PA-001; otherwise Philippine L1 or another approved existing employee acts in CMS data-custodian capacity for the narrow manual submit; System Administrator/Software Engineering handle technical failure. | |
| PO-033 — Retain the submitted PAAF and CMS receipt | Store the exact payload, submission method/time, submitting identity or service, CMS acknowledgment/response, and linked source evidence so the transaction can be reconstructed. | Necessary proof for PMP §2.7 and RFA Participant Monitoring and Auditing. | Capture the receipt, index the evidence, and identify a missing acknowledgment. | No for successful capture; yes only for a missing receipt, storage failure, or mismatch. | Software retains and reconciles; Philippine L1 pursues a missing CMS acknowledgment; System Administrator restores storage/access and Software Engineering fixes a product defect. | |
| PO-034 — Retrieve the real-time preliminary alignment notification | Retrieve the real-time notification, match it to the person and exact PAAF, preserve CMS's status/reason verbatim, and keep preliminary aligned separate from pending/final status. | PMP §2.7.2 and Appendix I. | Import the report, match it to the submission, and summarize the preliminary status and stated reason. | No when connected and matched; yes for manual portal retrieval, a missing result, or an identity mismatch. | Software retrieves/matches; Philippine L1 in approved data-custodian capacity performs manual retrieval or CMS administrative pursuit. | |
| PO-035 — Work pending or rejected preliminary results | Preserve CMS's stated reason, distinguish correctable administrative data, a clinical-source defect, CMS review, or unsupported category, and obtain only the required correction without telling the person they are aligned. | Necessary handling under PMP §2.7.2. | Classify the stated reason, assemble the relevant source evidence, and track correction or CMS follow-up. | No for an approved connected source correction or factual CMS follow-up; the appropriate Proxi employee acts only for manual pursuit, a genuine clinical/legal source judgment, or a required manual transmission. | Philippine L1/data-custodian capacity handles administrative correction and CMS pursuit; the original L3/L4 clinician corrects only clinical substance; Healthcare Legal Counsel handles a genuine uncovered legal issue; no generic program/compliance specialist. | |
| PO-036 — Retrieve the final Beneficiary Alignment Report result | Retrieve the final BAR, match it to the person and submission, preserve the final eligibility/alignment result, tier, reason, and effective date, and alert when it is absent or late. | PMP §2.7.2 and Appendix H. | Retrieve the BAR, match the patient and submission, and alert when the expected final result is absent. | No when connected and matched; yes for manual portal retrieval or a missing/mismatched result. | Software retrieves/matches; Philippine L1 in approved data-custodian capacity performs manual retrieval or CMS administrative pursuit. | |
| PO-037 — Reconcile the final alignment decision, tier, and effective date | Apply the final BAR status, tier, and effective date to the internal roster, care-activation gate, cadence calendar, and billing record; expose every mismatch without re-deciding CMS's result. | PMP §§2.7.2, 2.8, and Appendix H. | Match records, detect a changed tier or status, and create the operational handoff. | No for a clean match; yes only for source correction or a CMS dispute. | Software reconciles; Philippine L1 pursues administrative mismatches; Billing and Revenue Cycle resolves claim consequences; the original clinician enters only if the disputed source fact is clinical. | |
| PO-038 — Wait for final CMS confirmation before ongoing GUIDE service activation or billing | Keep preliminary and final alignment distinct and hold ongoing GUIDE activation and billing until the final BAR predicate is true, while permitting only the exact pre-alignment work CMS allows. | PMP §§2.7.2 and 2.9 and the June 2026 billing guidance in Appendix K. | Keep preliminary and final status distinct, allow internal planning without presenting it as final alignment or a furnished ongoing service, and hold activation and billing until the final BAR condition is met. | No for the gate; human service and claim work enter only after the gate under their own rows. | Software enforces the gate; Philippine L1 corrects a missing final artifact; Billing and Revenue Cycle handles only a disputed claim consequence. | |
| PO-039 — Send the aligned-patient notice within 45 days | Populate the current CMS aligned-patient template from the final BAR, calculate 45 days, render it accessibly, deliver through an approved channel, and retain delivery evidence. | PMP §2.7.3 and Appendix D. | Populate the current CMS template, calculate the deadline, prepare accessible delivery, and track completion. | No if approved policy/interface permits standing automatic delivery; one narrow human release only when current V1 or channel controls require it; L2 only for requested explanation or failed comprehension. | Software prepares/delivers on an approved class; otherwise the exact approved existing Proxi release performer is required under O-008/O-PA-001, with Philippine L1 handling administrative delivery failure and Puerto Rico L2 handling person-facing explanation. | |
| PO-040 — Retain proof that the aligned-patient notice was provided | Retain the exact notice/version, BAR trigger date, delivery timestamp/channel/destination, delivery/access result, and failed-delivery recovery evidence. | Necessary evidence for PMP §2.7.3. | Archive the notice and delivery evidence and flag an approaching or missed 45-day deadline. | No for successful automatic capture; yes only for failed delivery or missing proof. | Software retains and checks; Philippine L1 repairs address/channel facts and pursues delivery evidence; Puerto Rico L2 enters only for a person-facing barrier. | |
| PO-041 — Explain a non-alignment result and available next steps | Render CMS's stated non-alignment reason faithfully in plain language, offer only legitimate source-backed next steps, and preserve corrections/questions without changing the CMS result. | Optional route in PMP §2.7.3 and Appendix E. | Draft a plain-language explanation from the CMS result and prepare the optional CMS letter. | No for a clear approved explanation through an accepted mode; yes on request, failed comprehension, distress, contested facts, or required contractual conversation. | Software prepares/explains; Puerto Rico L2 supplies requested human explanation; Philippine L1 pursues administrative corrections; the original clinician addresses only a disputed clinical source fact. | |
| PO-042 — Calculate each annual-assessment window | From the accepted prior comprehensive-assessment date, calculate day 306, day 425, and the earlier submission deadline of 60 days after annual assessment start or day 425. | PMP §2.11. | Calculate and display the opening date, last safe start date, and final submission deadline. | No when the prior date is authoritative; yes only to correct a disputed source date. | Software calculates; Philippine L1 pursues source-date evidence. | |
| PO-043 — Schedule and start the annual assessment within days 306-425 | Offer and book a permitted assessment slot inside days 306–425 with adequate submission lead time, issue reminders, and escalate only actual booking/access risk. | PMP §2.11. | Generate due lists, schedule appointments, issue reminders, and flag cases at risk of missing the window. | No for connected scheduling; yes for manual booking or unresolved accessibility/preference needs; the separate assessment retains its own human work. | Software schedules; Philippine L1 performs manual booking; Puerto Rico L2 clarifies participation/preferences only when needed. | |
| PO-044 — Collect the current annual PAAF data set | Bring forward current accepted facts for verification, collect current beneficiary/caregiver responses, and link existing annual assessment, staging, attestation, residence, and measure products without duplicating their professional work. | PMP §§2.10-2.11 and Exhibit 6; PMM §2.2. | Prefill unchanged facts for verification, administer permitted structured items, and identify missing or changed fields. | Respondents and owning assessment professionals perform their source acts; no additional Program Operations reviewer; L1/L2 assist only on actual access/fact exceptions. | Software prepopulates/collects; Philippine L1 handles administrative gaps; Puerto Rico L2 handles required relationship questions; accepted L3/L4 products are reused. | |
| PO-045 — Renew the dementia attestation at the annual assessment | Present current source-linked annual clinical evidence to the roster clinician, who performs any necessary clinical work and signs the annual dementia attestation or records insufficiency/non-dementia. | PMP Exhibit 6 and §2.11. | Prepare the updated evidence and attestation field, but do not make or sign the clinical judgment. | Yes for every annual dementia attestation. | Proxi-supplied or contracted beneficiary-location-authorized L4 clinician on the Practitioner Roster; software prepares and retains the result. | |
| PO-046 — Renew the eligible-residence attestation and RCC fields annually | Reverify current address, setting, service area, RCC approval/arrangement, and Partner ID; prepare the exact annual residence attestation and update only changed fields. | PMP Exhibit 6 and §2.11. | Compare the current address and RCC roster with the prior record and flag any move or expired arrangement. | Only for a required official attestation/manual submit or a conflicting residence fact; no clinical reviewer. | Software compares/prepares; Philippine L1 pursues facts and may act in approved data-custodian capacity; the exact official signer remains governed by O-PA-001 and is not inferred from the Administrative Manager role. | |
| PO-047 — Submit the annual PAAF by the earlier deadline | After required attestations are complete, transmit the exact annual PAAF by the earlier of 60 days after assessment start or day 425 and retain the CMS receipt. | PMP §2.11; PMM §2.2. | Assemble the approved packet, calculate the controlling deadline, and support the authorized submission. | No for approved standing FHIR transmission; yes for a manual CMS-identity/portal act or transmission failure. | Software transmits on the approved connected path; otherwise an approved existing Proxi employee, potentially Philippine L1, acts in data-custodian capacity; System Administrator/Software Engineering handle technical failure. | |
| PO-048 — Reconcile the annual submission result and correct remediable errors | Match the CMS response to the annual PAAF, identify each rejected or changed field, correct only from attributable source evidence, resubmit through the permitted route, and reconcile accepted tier/status. | Necessary handling supporting PMP §2.11. | Match the response, identify rejections or tier changes, and route each correction. | No for a source-complete mechanical correction; yes for manual CMS pursuit, source-owner correction, or manual submit. | Software reconciles/prepares; Philippine L1/data-custodian capacity handles administrative correction and manual transmission; original L3/L4 professional corrects only clinical substance; Billing handles actual claim consequences. | |
| PO-049 — Detect changes that may require a reassessment PAAF | Compare new residence, dementia-stage, caregiver-status, and caregiver-burden facts with the last accepted PAAF and open only the applicable reassessment candidate without deciding the underlying clinical change. | PMP §2.10; PMM §2.2 footnote 13. | Compare new structured facts with the last accepted PAAF and alert the responsible owner. | No for detection; yes for missing facts or the separately required reassessment/clinical confirmation. | Software detects the changed source fact; Philippine L1 pursues administrative evidence; Puerto Rico L2 clarifies caregiver/residence facts. The qualified U.S. assessment professional establishes a changed stage only in PO-051, and the required roster practitioner separately attests. | |
| PO-050 — Submit an eligible-residence change reassessment on the permitted cadence | Verify the changed residence facts, apply the current cadence, prepare the exact residence reassessment and attestation, transmit through the approved HDR/FHIR route, and retain CMS receipt. | PMP §2.10 and Exhibit 6. | Prepare the residence-change packet, enforce the cadence, and flag RCC or ineligible-setting issues. | Only for missing/conflicting facts, a required official attestation, or manual portal transmission. | Software prepares/transmits when approved; Philippine L1 pursues facts and may act in approved data-custodian capacity; the exact attestation signer remains under O-PA-001; Administrative Manager/Healthcare Legal Counsel enter only for a new RCC arrangement or coverage commitment. | |
| PO-051 — Submit a dementia-severity change reassessment on the permitted cadence | Have the appropriate clinical professional assess the changed stage, obtain the required roster-clinician attestation, then apply the 180-day cadence and submit the exact reassessment through the approved route. | PMP §2.10 and Exhibit 6. | Collect the new tool responses, calculate the configured score, prepare the changed fields, and enforce the cadence. | Yes for the new staging interpretation/attestation; no second clinician after an accepted product; manual submit only if the interface requires it. | Beneficiary-location-authorized L3/L4 assessor within scope and dementia-proficient L4 roster clinician for required attestation; software prepares; approved existing employee in data-custodian capacity performs manual fallback. | |
| PO-052 — Submit a caregiver-status or burden reassessment on the permitted cadence | Capture changed caregiver status or direct ZBI-22 responses, apply the 180-day cadence, prepare the exact reassessment fields, transmit through the approved route, and open separate support/safety work when indicated. | PMP §2.10 and Exhibit 6; PMM §2.2 footnote 13. | Detect the change, present ZBI-22, prepare the reassessment fields, and enforce the cadence. | The caregiver supplies responses; no Proxi human on a clear approved path; L2 assists or provides triggered support, and a manual data custodian transmits only when required. | Software administers/scores/prepares; Puerto Rico L2 handles relationship/support exceptions; the exact U.S. clinician receives a clinical/safety trigger; approved existing employee in data-custodian capacity performs manual fallback. | |
| PO-053 — Keep reassessments separate from the annual requirement | Maintain independent reassessment and annual due paths, preserve the annual assessment date, and update tier only from the accepted CMS result. | PMP §§2.10-2.11; PMM §2.2 footnote 13. | Maintain both due paths, show the current accepted tier, and prevent a reassessment from closing the annual task. | No for routine tracking; yes only to correct a disputed source date or CMS result. | Software controls both clocks; Philippine L1/data-custodian capacity pursues source artifacts; Billing handles only claim consequences. | |
| PO-054 — Maintain the required interdisciplinary care team | Maintain filled, accepted, scheduled, and backed-up coverage for required navigator and clinical capabilities; detect vacancies, expiring authority, capacity shortfalls, and unsupported service promises. | Current PMP §§1.4.1–1.4.2 and §2.6, with the RFA care-team baseline and actual Agreement/portal instructions. | Maintain the staff directory, coverage view, qualification evidence, and vacancy alerts. | Yes for recruiting, contracting, appointment, coverage acceptance, and workforce repair; software performs monitoring. | HR and Workforce Administration recruits and maintains workforce/credential files; Head of Nursing and CMO establish the appropriate clinical coverage and backup; the actual qualified clinicians and Puerto Rico L2 accept their service assignments. Administrative Manager approves only a new partner or changed service/coverage commitment under D-027. | |
| PO-055 — Designate a trained human care navigator as primary contact | Establish the accepted currently trained primary PR navigator during the consented initial assessment/planning phase under D-032; retain accurate pending/final alignment status, assignment/effective date, backup and working contact route. Continue primary coverage for every applicable aligned person. | RFA Care Team Requirements and Appendix B §4. | Support assignment, workload visibility, reminders, and drafted communications while leaving the relationship and required human contact with the navigator. | The assigned L2 is a real human primary contact; the routine assignment itself may execute automatically under an approved staffing rule. | Software assigns from approved availability; HR and Workforce repairs capacity gaps; Puerto Rico navigator lead handles reassignment/dispute; the designated Puerto Rico L2 performs the actual relationship/service work, including the first useful family meeting during initial assessment/planning under D-032, not an extra welcome call or automatic service credit. | |
| PO-056 — Maintain a dementia-proficient Part B E/M clinician | Maintain contracted/employed, rostered, location-authorized, Medicare-eligible dementia-proficient L4 coverage with accepted backup for required clinical work and attestations. | Current PMP §§1.4.1–1.4.2 and §2.6, with the RFA care-team baseline and actual Agreement/portal instructions. | Track roster status, credentials, qualification evidence, and coverage gaps. | Yes for hiring/contracting, credentialing, coverage acceptance, and clinical service; software monitors status. | HR and Workforce Administration maintains workforce evidence; CMO establishes qualified clinical coverage and backup; the qualifying U.S. prescribing or Part B E/M clinician accepts and performs the actual clinical work. Administrative Manager approves only the D-027 partner/service commitment, not clinical qualification. | |
| PO-057 — Document the clinician's dementia-proficiency basis | Retain the current PMP dementia-proficiency basis: clinician attestation that at least 25% of the patient panel at some time in the past five years had cognitive impairment, OR at least 25% were adults aged 65 or older, OR the specified qualifying specialty designation. Link the accepted basis, signer, dates and CMS roster approval; this does not substitute for actual license/scope. | Current PMP §§1.4.1–1.4.2 and §2.6, with the RFA care-team baseline and actual Agreement/portal instructions. | Collect the evidence, test completeness, and alert before a qualification or roster gap affects care. | No for evidence-file assembly; yes when the clinician must make/sign a panel attestation or HR must cure a credential gap. | Software assembles/checks; HR and Workforce Administration maintains credential files; the qualifying L4 clinician signs their own required attestation; CMO resolves a genuine clinical-qualification dispute. | |
| PO-058 — Appoint a physician medical director when required | When the qualifying dementia-proficient clinician is not a physician, execute and retain the physician-medical-director appointment, scope, coverage, acceptance, and backup before relying on the configuration. | RFA Care Team Requirements. | Detect when the condition applies and maintain appointment and coverage evidence. | Yes when the condition applies. | CMO or the actually appointed qualified physician accepts the part-time medical-director capacity; HR and Workforce Administration maintains the appointment evidence. Administrative Manager enters only for a new clinical-partner or changed service commitment under D-027; signing authority remains distinct. | |
| PO-059 — Keep every team member within license and scope | Apply the approved jurisdiction/credential/scope matrix to each assignment, block out-of-scope work, and route the exact protected act to an authorized professional. | RFA Appendix B §§1.1.3.2 and 4.2.1. | Show role boundaries, flag out-of-scope assignments, and route triggered clinical questions. | No for clean rule enforcement; yes to correct a credential/assignment defect or resolve an uncovered professional-scope question. | Software enforces; HR and Workforce corrects files/assignments; Head of Nursing resolves nursing-practice scope; CMO resolves physician/medical scope; Healthcare Legal Counsel handles an uncovered legal-scope question. | |
| PO-060 — Maintain the GUIDE Practitioner Roster | Compare accepted workforce/credential facts with the CMS Practitioner Roster, prepare exact adds/changes/removals and effective dates, transmit through the approved interface, and retain CMS disposition. | Current PMP §§1.4.1–1.4.2 and §2.6, with the RFA care-team baseline and actual Agreement/portal instructions. | Compare credentialing data with the CMS roster and produce additions, removals, and mismatches for authorized submission. | No for approved automated synchronization; yes for manual CMS portal work, credential correction, or an organizational approval required by current instructions. | Software compares/prepares; HR and Workforce owns source credential facts; an approved existing employee, potentially Philippine L1, acts in data-custodian/roster-submit capacity for manual fallback; System Administrator restores access. | |
| PO-060A — Confirm GUIDE practitioner assignment and billing-rights prerequisites | Match practitioner, NPI, TIN, Medicare assignment, reassigned billing rights, relationship, and effective dates before roster reliance or claim release. | PMP §1.4.1; exact roster and reassignment procedures remain subject to the Participation Agreement and portal instructions. | Compare approved practitioner, NPI, TIN, assignment, reassignment, and effective-date facts and surface any mismatch before claim release. | No for complete authoritative matches; yes for credentialing/reassignment or billing exceptions. | Software matches; HR and Workforce corrects practitioner/relationship records; Billing and Revenue Cycle resolves assignment/reassignment and claim-release exceptions; the practitioner supplies required external enrollment acts. | |
| PO-061 — Maintain the Partner Organization Roster | Reconcile active approved partner contracts, CMS approval/effective dates, assigned services, identifiers, and terminations with the CMS Partner Organization Roster and prepare exact changes. | RFA Participation Requirements; FAQ Q14. | Compare active contracts and service assignments with the CMS roster and flag stale or missing partners. | No for clean synchronization; yes for manual portal transmission, missing contract facts, or a new/change business approval. | Software reconciles; Philippine L1 pursues the contract/CMS records and performs approved manual roster work. Administrative Manager approves only the new partner/service commitment; Healthcare Legal Counsel answers only an uncovered legal issue. | |
| PO-062 — Maintain accurate service-area ZIP codes | Compare current committed delivery capacity with the complete CMS ZIP list, prepare adds/removals and effective dates, transmit the approved change, and retain the full downloaded result. | PMP §1.4.3. | Compare actual operations with the CMS list, identify gaps, and prepare the authorized update. | Yes for a new or reduced Proxi service-area commitment; no for routine list comparison; manual portal work only if required. | Administrative Manager approves the business coverage commitment; software compares/prepares; an approved existing employee in data-custodian/portal capacity submits manually; HR/clinical leaders confirm actual capacity inputs without becoming the business approver. | |
| PO-063 — Maintain approved data custodians and CMS portal access | Maintain an accepted access inventory, least privilege, coverage/backups, grants/revocations, training, and continuity for HDR, eDFR, roster, and portal operations. | Necessary delivery work for PMP §§2.7.1-2.7.2 and Appendix H. | Maintain an access inventory, surface coverage gaps, and prompt review when roles change. | Yes for access grants/revocations, identity enrollment, and coverage acceptance; software monitors. | System Administrator grants/removes approved access and restores configuration; HR and Workforce Administration supplies joiner/mover/leaver facts. The approved employee accepts the actual data-custodian capacity. Software Engineering enters only for a confirmed defect; no routine manager approval is added. | |
| PO-064 — Maintain qualifying CEHRT | Maintain qualifying CEHRT certification evidence, vendor/service continuity, approved integrations, security configuration, and recovery from operational failure. | RFA Participation Requirements. | Track attestation and vendor evidence, surface expiring or missing certification support, and prepare audit documentation. | Yes for vendor/contract decisions, configuration, incidents, and defects; no person for routine certification-date monitoring. | System Administrator maintains approved CEHRT operation; Software Engineering repairs a confirmed defect; the actual EHR vendor supplies certification evidence. A new business commitment uses its actual delegated approval, not an authority inferred from D-027; Healthcare Legal Counsel enters only for an uncovered legal issue. | |
| PO-065 — Prevent patient cost-sharing for GUIDE services | Apply zero-patient-balance controls to GUIDE services, inspect statements/partner feeds, block collections, and create correction/refund work for any prohibited charge. | Current FAQ Q11. | Check GUIDE charges and patient statements, flag a patient balance, and prepare correction and refund work. | No for clean automated prevention; yes for correction, refund, payer dispute, or partner noncompliance. | Software prevents/detects; Billing and Revenue Cycle corrects/refunds and resolves payment issues; Administrative Manager addresses a partner business breach; Healthcare Legal Counsel enters only for a genuine legal dispute. | |
| PO-066 — Assign initial training when a navigator joins | Assign the approved initial curriculum at navigator onboarding, calculate due dates, block independent navigator assignment until completion/qualification evidence exists, and record completion status. | RFA Care Navigator Training. | Enroll the navigator, calculate due dates, and prevent an incomplete training record from being treated as qualified. | No for routine assignment/tracking; yes to repair a workforce/training exception. | Software assigns/tracks; HR and Workforce Administration resolves onboarding/qualification gaps; Puerto Rico navigator lead performs same-lane remediation when approved. | |
| PO-067 — Cover every required navigator-training topic | Crosswalk the approved curriculum and learning evidence to every required GUIDE topic, identify gaps, and route only the missing topic to its authorized content owner before use. | RFA Care Navigator Training, Table 4. | Map course content to the required topics, identify coverage gaps, and maintain an auditable curriculum crosswalk. | No for crosswalk/completeness; yes at design time to approve or author missing content in the role's actual domain. | Software crosswalks the approved curriculum; the competent Puerto Rico navigator lead supplies nonclinical practice content. Head of Nursing or CMO supplies only newly required clinical content within actual scope; Healthcare Legal Counsel answers only an uncovered legal question. A copied approved course does not require another clinical blessing. | |
| PO-068 — Deliver at least 10 hours of didactic instruction | Deliver the approved didactic curriculum through allowed live or web-based modes, capture attributable attendance/completion time, and prevent sub-10-hour completion. | RFA Care Navigator Training. | Schedule content, track attendance and completed time, and flag a shortfall. | The employed navigator personally completes at least ten didactic hours; this is paid learner time even with web content. A paid instructor is needed only for a chosen live mode or required remediation. | Puerto Rico L2 is the learner; software delivers approved asynchronous content and records actual completion. A competent Puerto Rico navigator lead or other appropriately qualified canonical professional supplies only required live instruction in that professional's scope. | |
| PO-069 — Deliver at least 10 hours of live experiential training | Provide and supervise at least 10 live experiential hours through approved interactions, shadowing, case practice, or on-the-job training; record supervisor, activity, date, duration, and competency return. | RFA Care Navigator Training. | Schedule supervised experiences, capture supervisor verification, and total eligible live hours. | The navigator personally completes at least ten live, non-asynchronous experiential hours; an approved qualified supervisor/instructor also participates. Count each employee's learning time and shared instructor time separately. | Puerto Rico L2 learns and a competent Puerto Rico navigator lead supervises nonclinical practice. Head of Nursing, CMO or the appropriately authorized U.S. clinician contributes only where the content or supervised act requires that authority; an approved outside instructor supplies its own segment. Philippine L1 lead may teach only the permitted administrative segment, not substitute for the full navigator experience. | |
| PO-070 — Administer the navigator comprehension assessment | Deliver and score the approved post-training assessment, identify missed domains, assign only the applicable remediation, and record the final qualification result under the approved threshold rule. | RFA Care Navigator Training. | Deliver and score the approved assessment, report missed domains, and track remediation. | The navigator personally answers the required comprehension assessment; learner and actual remediation time are paid workforce labor. Software delivery/scoring does not require another reviewer on a clean approved result. | Puerto Rico L2 takes the assessment; software delivers/scores under the approved rule; the competent navigator lead handles nonclinical remediation, and the actual authorized clinical educator handles only clinical content. HR and Workforce Administration maintains the accepted qualification record. | |
| PO-071 — Provide at least two additional training hours each year | Assign qualifying annual offerings, track at least two completed hours for every active navigator, and prevent expired/incomplete records from being treated as current. | RFA Care Navigator Training. | Maintain the annual due list, recommend approved offerings, and track completion. | Each active navigator personally completes at least two additional training hours annually. This is paid employee learning time; instructors enter only for live delivery or actual remediation. | Puerto Rico L2 completes the annual learning; software schedules/delivers approved web content/tracks. The qualified navigator lead, actual in-scope professional or approved outside CE provider supplies any required live content; HR and Workforce Administration repairs qualification records. | |
| PO-072 — Retain navigator qualification evidence | Retain curriculum/version, topic crosswalk, didactic/experiential hours, attendance, supervisor verification, assessment, remediation, annual hours, and current qualification status. | Necessary evidence for RFA Care Navigator Training and participant auditing. | Assemble the training file and identify missing proof before the navigator is scheduled. | No for routine assembly/retention; yes for missing evidence or disputed qualification. | Software assembles/checks; HR and Workforce Administration corrects the workforce file; the original supervisor corrects only their own evidence. | |
| PO-073 — Define what each partner organization will deliver | Create a source-linked responsibility schedule naming each service, population, geography, staffing, handoff, documentation, performance return, payment dependency, and gap/duplication before partner reliance. | Necessary delivery work supporting RFA Participation Requirements and FAQ Q14. | Create the service-responsibility summary, compare it with the required work, and expose gaps or duplication. | Yes for the business responsibility allocation and any clinical/legal scope approval; software drafts/crosswalks. | Administrative Manager approves the business/service split; Head of Nursing/CMO approves only clinical scope and safeguards; Healthcare Legal Counsel reviews genuine legal/contract terms; the partner supplies/accepts its own obligations. | |
| PO-074 — Execute a partner contract and payment arrangement before partner delivery | Negotiate, approve, sign, and retain the partner contract/payment arrangement with required services, dates, payment, evidence, safeguards, termination, and service-start dependencies before delivery. | Current FAQ Q14. | Track required agreement elements, signatures, effective dates, and service start dependencies. | Yes for the actual binding business approval and authorized signature; negotiation only when needed. Legal Counsel enters for changed/uncovered legal terms, not every approved-template transaction. | Administrative Manager approves the prepared Proxi business commitment; Billing and Revenue Cycle checks payment-operation exceptions; Healthcare Legal Counsel answers only a genuine uncovered legal question. The actual duly authorized signatories execute the contract; signing authority is not inferred from D-027. | |
| PO-075 — Add and update partners on the CMS roster as changes occur | After approved contract/business changes, prepare exact CMS partner roster adds/changes/removals, transmit through the approved interface, and retain CMS status/effective dates. | Current FAQ Q14; RFA Participation Requirements. | Compare contracts with the CMS roster and prepare the authorized update and evidence. | No for approved automated synchronization; yes for manual portal submission or a source mismatch; business approval occurs before this row. | Software prepares/synchronizes; an approved existing employee, potentially Philippine L1, acts in data-custodian/roster capacity for manual fallback; Administrative Manager and Healthcare Legal Counsel enter only for the underlying business/contract change. | |
| PO-075A — Obtain CMS approval before any partner begins GUIDE delivery | Hold partner GUIDE delivery until the exact CMS approval and effective date are present for the organization/service date; keep work with an already approved route meanwhile. | PMP §1.4.2; current portal and Participation Agreement instructions control the exact approval process. | Compare proposed service dates with CMS partner approval and effective dates and identify any work that must remain with the participant until approval. | No for the approval gate; yes only for missing approval evidence or the separate CMS application/cure. | Software enforces; Philippine L1/data-custodian capacity pursues CMS status; Administrative Manager/Healthcare Legal Counsel handle only application or arrangement deficiencies; CMS decides approval. | |
| PO-075B — Oversee partner-delivered GUIDE work | Reconcile assigned partner obligations, actual service evidence/dates, documentation returns, approved staffing, payment, and corrective actions; escalate only the exact performance defect. | PMP §1.4.2; exact arrangement terms remain subject to the Participation Agreement. | Compare assigned work with received service evidence, surface missing delivery or documentation, and prepare partner follow-up. | Yes for material performance correction, contract remedy, or clinical-quality defect; no human for routine evidence matching. | Philippine L1 pursues missing records; the original service worker and same-lane lead correct performance failures; Billing and Revenue Cycle resolves payment exceptions. Head of Nursing or CMO enters only for the clinical-quality issue in scope. Administrative Manager handles only a D-027 contract/service commitment, and Healthcare Legal Counsel only a genuine legal dispute. | |
| PO-076 — Classify a congregate setting before treating it as an RCC | Collect facility, campus, unit, bed, services, permanence, and source facts and apply the approved CMS setting taxonomy without inferring category from a name or marketing label. | Current FAQ Q8; PMP §§2.4 and 2.12. | Collect the facility and unit facts, normalize the setting, and flag ambiguous descriptions for compliance review. | No for complete facts covered by the approved taxonomy; yes for source pursuit or a verified case the rule does not cover. | Software classifies under the approved rule; Philippine L1 verifies facility facts; Puerto Rico L2 clarifies lived-arrangement facts; Healthcare Legal Counsel answers only a complete uncovered authority question. | |
| PO-077 — Obtain CMS approval before adding an RCC partner | Assemble verified RCC facility, service, arrangement, roster, and requested CMS fields, transmit the approval packet through the approved route, and retain CMS disposition/effective date before reliance. | PMP §§1.4.2 and 2.8.1; current FAQ Q14. | Prepare the approval packet from verified facility and arrangement data and track CMS disposition. | No for approved connected transmission after business/legal inputs are complete; yes for manual CMS submission, negotiation, or cure. | Software prepares/tracks; an approved existing employee in data-custodian capacity submits manually; Administrative Manager approves the Proxi business request; Healthcare Legal Counsel handles arrangement/legal deficiencies; CMS decides approval. | |
| PO-078 — Execute the enhanced RCC Partner Organization Arrangement | Negotiate, approve, execute, and retain the current compliant enhanced RCC arrangement with required provisions, dates, services, safeguards, payment, termination, and CMS dependency before relying on it. | PMP §2.8.1; current FAQ Q14. | Track the current CMS-required provisions, signatures, dates, and approval dependency without supplying legal approval. | Yes for the actual binding business approval and authorized signatures; legal negotiation only when current required terms expose a genuine uncovered question. | Administrative Manager approves the Proxi RCC business commitment; the actual duly authorized Proxi/Participant and RCC signatories execute their required acts. Healthcare Legal Counsel enters only for a genuine uncovered legal issue, and Billing and Revenue Cycle handles payment-operation exceptions. Exact mandatory Participant signature remains O-PA-001. | |
| PO-079 — Record and use the approved RCC Partner ID | Match the CMS-issued Partner ID to the exact facility/address, approval, arrangement, and effective date and populate only matching patient/PAAF records. | PMP §§2.7 and 2.8.1; Exhibit 6. | Match facility, address, approval, and Partner ID and block a mismatched or missing ID from a clean submission. | No for a clean match; yes only to correct a source mismatch. | Software matches/populates; Philippine L1 in approved data-custodian capacity pursues CMS/roster correction. | |
| PO-080 — Monitor RCC approval and arrangement status over time | Continuously compare approval/effective dates, arrangement dates/termination/material changes, unit changes, Partner ID, and resident roster; open only the affected prerequisite or transition work. | Necessary delivery work for PMP §§2.8.1 and 2.12. | Compare agreement and roster dates with current patient residences and alert the responsible owners. | No for monitoring; yes for missing facts, contract action, CMS cure, or person-facing transition. | Software monitors; Philippine L1 pursues administrative facts; Administrative Manager/Healthcare Legal Counsel handle actual arrangement changes; Puerto Rico L2 handles triggered transition support. | |
| PO-081 — Run the 60-day RCC transition when both approval and a compliant arrangement are absent | At move-awareness, record CMS approval and compliant-arrangement status separately. Approved+arranged follows the ordinary RCC route. Unapproved+unarranged enters the public PMP §2.12 60-day transition to obtain both prerequisites or complete transition/unalignment. Approved+unarranged and unapproved+arranged hold the affected RCC service/billing/alignment act for exact Participation Agreement or CMS interpretation; neither is assumed compliant, automatically graced, or automatically unaligned. | PMP §§1.4.2, 2.4, 2.8.1 and 2.12; mixed-case interpretation remains O-024/O-PA-001. | Retrieve dated approval/arrangement facts separately, calendar the verified awareness date, prepare the approval/contract/PAAF material, track both prerequisites and preserve the correct transition/CMS result. AI does not approve a contract, classify an unsupported case or extend the window. | Yes for actual arrangement negotiation/business approval and for required person-facing transition help; no for clocking, reminders, evidence matching, or packet preparation; manual CMS submission only if required. | Software evaluates the four cases and tracks the clock; Philippine L1 pursues approval/arrangement evidence; Administrative Manager and Healthcare Legal Counsel handle actual business/legal arrangement work; Puerto Rico L2 provides triggered transition planning/support; approved existing employee in data-custodian capacity submits CMS artifacts; L3/L4 enters only for a separate clinical transition need. | |
| PO-082 — Run the 15-day transition for a move to a Memory Care Unit | From verified awareness of a Memory Care Unit move, start the 15-day transition, prepare required unalignment data, identify open commitments, provide accessible transition planning/support, submit through the approved route, and preserve completion evidence. | PMP §2.12; current FAQ Q8. | Start the deadline, prepare the transition checklist and PAAF, and track completion. | Yes for person-facing transition planning/support; no for clocking/packet assembly; manual CMS submit only if required; clinical professional only for a distinct care question. | Puerto Rico L2 performs transition planning/support; Philippine L1 gathers records/logistics and may act in approved data-custodian capacity; L3/L4 performs only triggered clinical handoff work; software tracks/prepares. | |
| PO-083 — Calendar the current care-delivery reporting window | Retrieve current-year GUIDE reporting instructions, questions, track, window, deadline, accepted route, and owners from the authoritative source rather than carrying historical dates forward. | RFA Care Delivery Reporting; exact current-year instructions remain subject to GUIDE Connect and the Participation Agreement. | Maintain the due date, required questions, owners, and evidence requests. | No through a maintained authoritative source; yes for manual portal retrieval or conflicting instructions. | Software retrieves/calendars; Philippine L1 in approved data-custodian capacity retrieves manually; System Administrator restores access; Software Engineering fixes parsing defects. | |
| PO-084 — Gather the facts for care-delivery reporting | Aggregate actual service, cadence, modality, staffing, partner, delivery, and evidence records for each current CMS question; draft source-linked factual answers and expose unsupported contradictions. | RFA Care Delivery Reporting; current FAQ Q17. | Aggregate records, draft factual answers, and identify unsupported or contradictory claims. | No for authoritative aggregation; yes only for a source owner to correct an actual missing/contradictory record. | Software aggregates/drafts; Philippine L1 pursues administrative records; each canonical service performer corrects only their own source record; Head of Nursing/CMO enters only if the requested answer requires new clinical interpretation. | |
| PO-085 — Validate and submit care-delivery reporting | Validate current required fields and source support, obtain only required organizational/content approvals or attestations, transmit through the current approved route, and retain the exact submitted version/receipt. | RFA Care Delivery Reporting. | Run completeness checks, preserve approvals, and support the authorized CMS submission. | Only for an expressly required approval/attestation or manual submit; no blanket quality/compliance review. | Software validates the factual report; original source workers correct only their own records. An approved existing employee performs a required manual submission. Any required institutional attestor remains unassigned under O-PA-001. The Administrative Manager enters only if a reported proposal changes Proxi's D-027 service/coverage/partner commitment; clinical leaders enter only for new clinical interpretation, not copied clinical text. | |
| PO-086 — Retain support for every care-delivery reporting response | Link each submitted answer to exact source records, calculations, policy/version, approvals, samples, period, and receipt and flag unsupported or superseded evidence. | Necessary audit evidence for RFA Care Delivery Reporting and Participant Monitoring and Auditing. | Link each response to its support and flag unsupported assertions. | No for routine linking/retention; yes only for source correction or a genuine evidentiary dispute. | Software retains/links; Philippine L1 pursues missing records; the exact canonical performer who created the source corrects that record; Healthcare Legal Counsel handles a genuine audit/legal evidence dispute. | |
| PO-087 — Maintain and annually update the Health Equity Plan | Update the annual plan from approved disparity analyses, populations, measures, goals, interventions, owners, implementation evidence, and prior results; make business and clinical choices explicit. | RFA Health Equity Plan Requirement. | Assemble the plan from approved analyses and actions, track owners and updates, and show missing evidence. | Yes for selecting/approving goals and interventions; software assembles/tracks. | Software prepares source-linked measures/results; the competent Puerto Rico navigator lead proposes or adjusts approved nonclinical practice, Head of Nursing or CMO supplies actual clinical-intervention judgment, and Billing and Revenue Cycle resolves financial findings. Administrative Manager approves only changed D-027 service/coverage/partner commitments. Any separately required institutional approval follows the actual Agreement/reporting instructions under O-PA-001. | |
| PO-088 — Measure Health Equity Plan progress and adjust approved interventions | Calculate approved measures, compare them with goals and implementation evidence, identify weak or unequal results, and have the appropriate owner select, continue, revise, or stop the exact intervention. | RFA Health Equity Plan Requirement. | Calculate approved measures, summarize progress, and surface disparities or weak implementation for human action. | Yes for intervention disposition; no for measure calculation and trend detection. | Software prepares source-linked measures/results; the competent Puerto Rico navigator lead proposes or adjusts approved nonclinical practice, Head of Nursing or CMO supplies actual clinical-intervention judgment, and Billing and Revenue Cycle resolves financial findings. Administrative Manager approves only changed D-027 service/coverage/partner commitments. Any separately required institutional approval follows the actual Agreement/reporting instructions under O-PA-001. | |
| PO-089 — Report Health Equity Plan progress annually | Populate the current CMS section from approved plan goals, interventions, measures, progress, and changes; validate source links, obtain only required approvals/attestation, transmit, and retain receipt. | RFA Health Equity Plan Requirement and Care Delivery Reporting. | Draft the section from verified plan records, check completeness, and preserve the submitted version. | Only for required organizational/content approval, official attestation, or manual submission. | Software reuses approved plan facts and drafts the report; Philippine L1 pursues administrative gaps or performs an approved manual submission. Any required institutional attestor remains unassigned under O-PA-001; no manager or clinician re-approves unchanged accepted facts. | |
| PO-090 — Ask willing aligned patients for required sociodemographic data | Present the current voluntary sociodemographic questions accessibly, capture direct responses or refusal exactly, validate allowed values, and avoid coercion or invented values. | RFA Health Equity Data Collection Requirement. | Present approved questions, capture the patient's responses or refusal, validate allowed values, and support language access. | The beneficiary/representative supplies the choice; no Proxi human on a clear approved digital/AI path; L2 or interpreter support only when requested or needed for accessibility/comprehension. | Software presents/captures; Puerto Rico L2 provides human support; Philippine L1 handles administrative mode/access issues. | |
| PO-091 — Ask willing aligned patients for required HRSN data | Present the current voluntary HRSN screen accessibly, capture attributable responses/refusal, and route each identified need to its owning navigation, Medicaid, clinical, or safety task rather than treating it only as reporting data. | RFA Health Equity Data Collection Requirement. | Present an approved screen, record responses or refusal, summarize needs, and alert the responsible navigator. | The beneficiary/representative supplies answers; no Proxi human for clear capture; L2 acts on accepted nonclinical needs, Medicaid specialist on program questions, and clinician only on a clinical/safety trigger. | Software screens/routes; Puerto Rico L2 handles navigation needs; Medicaid Program Specialist handles Medicaid questions; exact U.S. clinician handles clinical/safety triggers. | |
| PO-092 — Aggregate and report annual sociodemographic and HRSN data | Aggregate valid patient-level responses/refusals, reconcile denominators, apply current CMS validation/suppression rules, prepare the exact annual submission, transmit through the approved route, and retain receipt. | RFA Health Equity Data Collection Requirement and Data Reporting Requirements. | Aggregate, reconcile denominators, run suppression or validation rules supplied by CMS, and prepare the submission. | No for calculation/preparation or approved automatic transmission; yes for a missing-source correction, required attestation, or manual submit. | Software aggregates/validates; Philippine L1 pursues administrative gaps and may act in approved data-custodian capacity; exact official signer remains governed by current instructions/O-PA-001; no generic privacy/quality reviewer. | |
| PO-093 — Maintain the participant-reported performance-data calendar | Calendar the current patient-level initial/annual deadlines and the exact performance-year acceptance date from PMM Exhibit 5/current CMS instructions. The final survey-data deadline is not an extension of the individual's 60-day/annual deadline; use the actual stated weekday date rather than an undated end-of-August label. | PMM §§2.1-2.2 and Exhibit 5. | Calculate patient-level and performance-year deadlines and flag submissions at risk. | No for current authoritative rules; yes only to resolve conflicting source dates/instructions. | Software calculates; Philippine L1/data-custodian capacity retrieves current instructions; System Administrator restores source access. | |
| PO-094 — Submit complete PROMIS-10 and applicable ZBI-22 performance data | Validate direct beneficiary/caregiver responses, applicability, item completeness, assessment linkage, and deadlines; build the exact current PAAF/FHIR submission, transmit through the approved route, and retain receipt. | PMM §§2.1-2.2 and Exhibit 5. | Validate item-level completeness, assemble the current worksheets or approved submission, and support authorized submission. | Respondents supply answers; no new clinical review for accepted data; manual data-custodian submit only when required; source owner corrects an actual field defect. | Software validates/prepares/transmits when approved; Philippine L1/data-custodian capacity handles manual fallback; original assessment professional corrects only their own source record. | |
| PO-095 — Reconcile performance-data coverage to the aligned population | Match accepted PROMIS-10/ZBI-22 records to BAR population and measure eligibility, keeping no caregiver, refusal, missing assessment, rejected PAAF, and late data distinct. | Necessary performance work under PMM §§2.1-2.4. | Calculate coverage, produce a patient-level exception list, and trace each gap to its source. | No for reconciliation; yes only for administrative source pursuit or correction of an underlying source product. | Software reconciles; Philippine L1 pursues administrative gaps; Puerto Rico L2 clarifies caregiver/refusal facts; original L3/L4 professional corrects only a clinical assessment record. | |
| PO-096 — Follow the current PY 2026 high-risk-medication reporting rule | Maintain the current measure-source map showing claims-based DAE calculation, suppress obsolete participant HRRx workbook work, and update only from a current PMM change. | PMM §2.3. | Compare the reporting calendar with the current PMM and remove obsolete participant-reporting work. | No for current rule enforcement; yes only for an authoritative rule change or product defect. | Software enforces; Philippine L1/data-custodian capacity retrieves current PMM instructions; Software Engineering updates a confirmed implementation defect; CMO interprets only a genuine clinical-program implication, not routine reporting. | |
| PO-097 — Review quarterly DFT results and the annual PBA workbook | Import and trend DFT/PBA measures, reconcile denominators with internal evidence, explain anomalies with sources, and have the appropriate accountable leader select any quality-improvement action. | PMM §§2.4-2.5. | Import the workbook, trend measures, identify denominator or performance anomalies, and draft a review packet. | Yes for interpretation of material anomalies and action selection; no for import/trending. | Software prepares source-linked measures/results; the competent Puerto Rico navigator lead proposes or adjusts approved nonclinical practice, Head of Nursing or CMO supplies actual clinical-intervention judgment, and Billing and Revenue Cycle resolves financial findings. Administrative Manager approves only changed D-027 service/coverage/partner commitments. Any separately required institutional approval follows the actual Agreement/reporting instructions under O-PA-001. | |
| PO-098 — Correct remediable performance-data problems before the deadline | Identify the rejected/duplicate/mismatched field, trace it to exact source evidence, prepare only a permitted correction, transmit through the approved route before deadline, and track acceptance. | Necessary delivery work supporting PMM §2.2. | Identify the exact failed record and field, assemble its source, route approval, and track accepted correction. | No for a mechanical source-backed correction; yes for source pursuit, source-owner correction, required approval, or manual submit. | Software diagnoses/prepares; Philippine L1/data-custodian capacity handles administrative correction/manual transmission; original L3/L4 professional corrects clinical substance; Healthcare Legal Counsel handles a genuine authority issue. | |
| PO-099 — Maintain the GUIDE audit file | Index exact reporting, roster, training, payment, assessment, notice, consent, service, partner, and CMS transaction evidence under the approved retention schedule and preserve provenance/immutability. | RFA Participant Monitoring and Auditing. The public RFA defers exact retention policy to the Participation Agreement. | Index reporting, roster, training, payment, assessment, notice, and care-delivery support and flag missing periods. | No for routine retention/completeness; yes to approve/change retention policy or resolve a legal hold/evidentiary dispute. | Software retains/checks under approved retention rules; System Administrator restores storage/access; Philippine L1 pursues missing administrative evidence. Healthcare Legal Counsel handles a genuine uncovered retention/legal-hold question; the original author corrects that author's evidence. D-027 does not establish a new routine retention-policy approver. | |
| PO-100 — Respond to CMS monitoring and audit requests | Inventory the exact request, preserve source records, assemble complete source-linked evidence, obtain only domain-specific factual/authority returns, approve the organizational response, submit by deadline, and retain receipt without altering originals. | RFA Participant Monitoring and Auditing. | Create the request inventory, collect linked evidence, detect omissions, and track owner approvals and due dates. | Yes for the substantive audit response and organizational release; routine evidence collection is automated/L1. | Philippine L1 assembles/pursues the prepared response; Billing and Revenue Cycle handles financial evidence; the original clinical author or Head of Nursing/CMO supplies only an actual clinical explanation within scope; Healthcare Legal Counsel answers genuine legal issues. The exact required institutional response/submit authority follows the actual request/Agreement under O-PA-001, not a blanket Administrative Manager assignment. | |
| PO-101 — Cooperate with the independent GUIDE evaluation | Track evaluation requests, schedule actual requested surveys/interviews/site visits, prepare approved factual materials, support permitted evaluator access, record staff participation, and preserve completion evidence. | Current FAQ Q17; RFA Evaluation. | Track requests, schedule participants, assemble approved factual materials, and record completion. | Yes for requested interviews, surveys, site visits, and organizational decisions; no for scheduling/packet assembly. | The specifically requested canonical-role employee supplies that employee's interview/survey/site-visit contribution; Philippine L1 schedules and assembles; System Administrator supports approved access. Exact institutional commitments/authority follow the actual request/Agreement. Administrative Manager enters only for a changed D-027 business commitment, not every evaluation response. | |
| PO-102 — Keep the Beneficiary Alignment Report reconciled | Import each current BAR and reconcile beneficiary identity, alignment status, tier, residence, effective dates, internal roster, service activation, and billing; produce an exact exception list. | PMP §2.13 and Appendix H. | Import the current BAR, match records, and produce an exception list. | No for matched records; yes for manual retrieval, source correction, or CMS mismatch pursuit. | Software imports/reconciles; Philippine L1/data-custodian capacity handles manual retrieval/pursuit; Billing and Revenue Cycle resolves claim effects; the exact canonical performer who created a mismatched source corrects that fact. | |
| PO-103 — Monitor Medicare coverage and payer changes | Monitor authorized A/B, Medicare-primary, MA/SNP/PACE, and effective-date changes, distinguish pending from active changes, and open only the applicable transition/billing work. | PMP §2.13.1. | Compare authorized eligibility data over time and flag an effective or pending disqualifying change. | No for authoritative connected monitoring; yes for missing/conflicting payer evidence or manual transition help. | Software monitors; Philippine L1 pursues administrative evidence; Billing and Revenue Cycle resolves payer/claim exceptions; Puerto Rico L2 handles triggered person-facing transition support. | |
| PO-104 — Monitor hospice election, death, nursing-home residence, and prolonged inactivity | Detect authorized hospice/death/residence events and eight consecutive months without either a DCMP or GUIDE Respite Services CLAIM. Preserve event/effective/awareness dates and separately open verification, communication, transition or unalignment work. Actual services and submitted claims are different evidence; service activity alone does not reset the claims-based condition. | PMP §2.13.1. | Compare authorized claims, eligibility, residence, and internal activity records and flag a potential CMS unalignment. | No for detection; yes for missing fact verification, sensitive communication/transition, or a distinct clinical care question. | Software detects; Philippine L1 verifies administrative sources; Puerto Rico L2 performs sensitive family/transition communication; Billing handles claims; L3/L4 enters only for clinical transition needs. | |
| PO-105 — Monitor residence and service-area changes | Capture move awareness/effective dates, address, setting/unit, permanence, service area, RCC approval/arrangement, and Partner ID; apply the approved route and open PO-081/082 only when its predicate is met. | PMP §§1.4.3, 2.12, and 2.13.2. | Compare new address and setting with service-area and RCC data, calculate transition dates, and route the case. | No for clear direct/authoritative facts and rule result; yes for factual pursuit, ambiguous setting, business coverage decision, or person-facing transition. | Software monitors/routes; Philippine L1 verifies facts; Puerto Rico L2 clarifies living arrangements and transition needs; Administrative Manager approves new coverage commitments; Healthcare Legal Counsel handles uncovered legal questions. | |
| PO-106 — Act on evidence that the patient no longer has dementia | Assemble source-linked evidence for the roster clinician, who performs any necessary clinical evaluation and signs the exact no-longer-has-dementia attestation; only then prepare and transmit the required unalignment artifact. | PMP §2.13.2. | Collect the clinical evidence and prepare the unalignment data, but never decide or sign the diagnostic attestation. | Yes for the clinical attestation; manual CMS submit only if the interface requires it. | The beneficiary-location-authorized U.S. prescribing or Part B E/M clinician on the GUIDE Practitioner Roster with actual diagnostic authority evaluates/signs the written no-longer-dementia attestation. The public clause does not additionally require the designated dementia-proficient title. Software prepares; an approved existing employee transmits; Puerto Rico L2 provides separately needed nonclinical transition support. | |
| PO-107 — Receive and document a request to stop GUIDE services | Capture the authenticated beneficiary/caregiver stop request, speaker/authority, exact scope, awareness time, any independent safety issue, and a non-coercive acknowledgment; start the 15-business-day clock. | PMP §§2.13.2 and 2.14; Appendix G. | Capture the request, calculate the 15-business-day deadline, and prepare an acknowledgment. | The beneficiary/caregiver supplies the choice; no Proxi human for a clear approved digital request; L1/L2 enters when the request is verbal, ambiguous, inaccessible, distressed, or contested. | Software records direct requests; Philippine L1 captures a verbal administrative request; Puerto Rico L2 clarifies scope/relationship without pressuring the choice; Healthcare Legal Counsel handles only an authority dispute. | |
| PO-108 — Submit stop-request unalignment within 15 business days | Build the exact unalignment PAAF from the authenticated stop request, calculate 15 business days, transmit through the approved HDR/FHIR route, and retain CMS receipt/result. | PMP §2.14 and §2.13.2. | Prepare the PAAF from the documented request, calculate business days, and support the authorized submission. | No for approved standing connected transmission; yes for manual CMS-identity/portal submit or failed transmission. | Software prepares/transmits when approved; otherwise an approved existing employee, potentially Philippine L1, acts in data-custodian capacity; System Administrator/Software Engineering handle technical failure. | |
| PO-109 — Submit mandatory participant-reported ineligibility unalignment | For an approved mandatory reason, assemble exact setting/service-area or signed dementia-status evidence, event/awareness/effective dates, build the unalignment PAAF, transmit through the approved route, and retain result. | PMP §2.13.2. | Assemble the verified reason, dates, and supporting evidence and prepare the authorized PAAF. | No for deterministic residence/service-area reason and approved connected transmission; yes for missing facts, required dementia attestation, mixed RCC interpretation, or manual submit. | Software prepares/transmits; Philippine L1/data-custodian capacity handles facts/manual fallback; L4 signs the dementia-status attestation only for that branch; Administrative Manager decides only a new service-area business commitment; Healthcare Legal Counsel handles mixed/uncovered authority questions. | |
| PO-110 — Optionally report death, hospice election, or planned permanent nursing-home move | Verify the optional-report event and dates, apply the preapproved report/no-report policy, prepare and transmit the exact PAAF when the policy says report, and track CMS result without delaying necessary transition support. | PMP §2.13.2. | Gather the verified event evidence, prepare the optional PAAF, and track the CMS result. | No case-by-case manager approval under a settled policy; yes for missing/conflicting evidence, a policy gap, manual submit, or separate person-facing/clinical transition work. | Software applies only an approved report/no-report rule; Philippine L1 verifies the event and performs approved manual data-custodian work; Puerto Rico L2 supplies separately needed sensitive support. A policy gap holds only the unsupported act for the actual organizational authority; D-027 is not a new general disposition power. | |
| PO-111 — Confirm the CMS unalignment result and effective date | Retrieve and match the updated BAR, apply the correct standard or special CMS end date, and propagate it to service, notice, transition, and billing controls without assuming month-end. | PMP §§2.13.2-2.13.3. | Match the CMS result, calculate the operational stop date, and flag a conflict with the reported event. | No for a matched CMS result; yes for missing/mismatched BAR or disputed claim consequence. | Software retrieves/reconciles; Philippine L1/data-custodian capacity pursues CMS artifacts; Billing and Revenue Cycle handles claim/date exceptions. | |
| PO-112 — Send the required unalignment notice within 30 days | Select the current Appendix F notice, apply the deceased/hospice exception exactly, populate from the BAR, calculate 30 days, render accessibly, deliver through the approved channel, and retain proof. | PMP §2.13.4 and Appendix F. | Populate the current template, calculate the deadline, apply the stated exception, and track delivery. | No if approved policy/interface permits standing delivery; one narrow release act only where current V1/channel controls require it; L2 only for requested/sensitive explanation. | Software prepares/delivers on an approved class; exact existing Proxi release performer remains governed by O-008/O-PA-001 where human release is required; Philippine L1 repairs delivery facts; Puerto Rico L2 handles person-facing explanation. | |
| PO-113 — Retain proof of the unalignment notice or documented exception | Retain the BAR trigger date, exact notice/version, delivery evidence/result, failed-delivery recovery, or authoritative deceased/hospice exception evidence. | Necessary evidence for PMP §2.13.4 and Appendix F. | Archive the record and alert before the 30-day deadline expires. | No for successful capture; yes only to obtain missing proof or resolve conflicting exception evidence. | Software retains/checks; Philippine L1 pursues delivery/administrative evidence; Healthcare Legal Counsel handles only a genuine exception-authority question. | |
| PO-114 — Cease GUIDE billing at the applicable unalignment date | Apply the CMS unalignment effective date and special timing rule to billing eligibility, stop disallowed GUIDE claims, and identify only claims requiring correction. | PMP §2.13.3. | Apply the BAR effective date to billing eligibility and flag claims that cross it. | No for automatic billing hold; yes for a manual claim correction, refund, denial, or disputed effective date. | Software enforces; Billing and Revenue Cycle performs manual financial correction; Philippine L1/data-custodian capacity pursues a missing BAR. | |
| PO-115 — Limit transition-period service and billing to the permitted window | Apply the validated No/No RCC 60-day or Memory Care Unit 15-day transition only to its applicable case. If both RCC prerequisites become effective, return to the ordinary RCC route, not an automatic day-60 stop. If status remains mixed/unknown use O-024/O-PA-001. Preserve the separate CMS alignment/date and required transition/submission work; a deadline never creates eligibility or service evidence. | PMP §2.12. | Display the permitted window, track required actions, and flag service or billing after its end. | No for the window control; people enter under PO-081/082 or a billing exception. | Software controls dates; Billing and Revenue Cycle resolves claim exceptions; Philippine L1 corrects source dates; Puerto Rico L2/clinical roles perform separately triggered transition work. | |
| PO-115A — Submit final GUIDE claims after Memory Care Unit unalignment within 30 days | Identify otherwise valid pre-unalignment GUIDE services not yet claimed, reject post-end service dates, construct final claims, submit within 30 days after effective unalignment, and reconcile responses. | PMP §2.12, Memory Care Unit important billing requirement. | Calculate the 30-day deadline, identify eligible pre-unalignment services not yet billed, prepare the final claims, and flag any service date after the CMS alignment end date. | No for automated approved claim transmission; Billing human for manual construction/release, exception, or denial. | Software calculates/builds; Billing and Revenue Cycle submits manually or resolves exceptions; Philippine L1/data-custodian capacity supplies missing BAR/service evidence. | |
| PO-116 — Coordinate continuity when GUIDE alignment ends | Prepare active commitments, current approved care information, contacts, deadlines, and options; conduct an accessible person-facing transition conversation; obtain choices; send accepted handoffs through approved routes; track receipt and unresolved needs. | Necessary delivery work supporting PMP §§2.12-2.14. | Assemble the active-care summary, open commitments, contacts, and patient-facing transition checklist. | Yes for the person-facing continuity/relationship act; clinical professional only for new or changed clinical content; logistics remain L1/software. | Puerto Rico L2 leads continuity discussion and nonclinical coordination; Philippine L1 gathers records/schedules/pursues receipts; existing L3/L4 clinical products are reused and the exact clinician enters only for a new clinical need. | |
| PO-117 — Cooperate when the patient changes GUIDE participants | Authenticate the new participant request, preserve the beneficiary's choice/permission, assemble only permitted current transition information, perform the approved release, coordinate unresolved handoffs, and track receipt within the required process. | PMP §2.14. | Prepare the authorized transfer packet, track the request and disclosure, and identify unresolved care handoffs. | Yes for relationship/transition coordination and any current V1 release; no new clinician if approved current clinical content already exists. | Puerto Rico L2 handles transition relationship work; Philippine L1 verifies endpoints/pursues records; exact approved release performer remains governed by O-008/O-021/O-PA-001; original clinician updates only genuinely stale/conflicted clinical content. | |
| PO-118 — Close the internal GUIDE episode only after required work is complete | Close deterministically only when the final CMS date, billing stop, required notice/exception, transition actions, open-work dispositions, and audit evidence are complete; leave each unmet prerequisite open with its existing owner. | Necessary closure work for PMP §§2.12-2.14. | Check each required completion fact, assemble the closure summary, and leave unresolved items open for the named owner. | No separate final approver; humans complete only their upstream prerequisites. | Software applies D-002 closure; every unmet prerequisite stays with the canonical performer named in its own row; no generic program or clinical closure reviewer is created. | |
| PO-119 — Build and maintain the potential-patient referral network | Identify and maintain referral routes, criteria, protocols, contacts, response evidence, and gaps with PCPs, neurology, hospitals, discharge teams, and community organizations; negotiate only approved relationships. | PMP §2.2. | Maintain the referrer directory, approved criteria, referral instructions, and source-by-source volume and follow-up list. | Yes for relationship formation, negotiation, and business approval; no for directory maintenance or drafted outreach. | Software maintains permitted contacts and approved outreach; Philippine L1 verifies factual referral routes; the competent Puerto Rico navigator lead performs genuinely needed relationship work. CMO supplies only newly needed clinical referral criteria; Administrative Manager approves only a new partner/service commitment and Healthcare Legal Counsel only an uncovered fraud/contract question. | |
| PO-120 — Conduct potential-patient outreach without coercion | Use the approved audience, purpose, content, channel, suppression, and accessibility rules to contact a potential patient, state why contact occurred, offer intake, record response/refusal, and never claim eligibility/alignment. | Necessary delivery work supporting PMP §2.2 and the voluntary-alignment protections in PMP §§2.3 and 2.14. | Prepare accessible outreach, schedule responses, record contact preferences and refusal, and flag language or accommodation needs. | No for an approved bounded digital/AI outreach class; L1 for manual channel/failure; L2 only for requested human explanation or relationship need; beneficiary decides whether to engage. | Software performs only the approved outreach class; Philippine L1 handles manual contact or administrative failure; Puerto Rico L2 supplies requested human explanation. The existing approved outreach policy controls the campaign; a new D-027 service/partner commitment uses Administrative Manager, not a new case-by-case approval. | |
| PO-121 — Document a temporary residence period | Record temporary location, dates, expected return and source; apply the documented snowbird rule without adding the temporary ZIP as a new service area. If the move becomes permanent or uncertain, re-evaluate service area and actual unit/setting under PO-105: use only the valid RCC/Memory Care route or other applicable status rule. Continue independent authorized care, not an invented grace period. | PMP §1.4.3 Snowbird Policy. | Capture dates and location, remind the team of the allowed route, and flag a move that appears permanent rather than temporary. | No for clear direct facts and rule application; yes for fact ambiguity, requested care-planning help, new business coverage commitment, or billing dispute. | Software captures/applies; Philippine L1 verifies facts; Puerto Rico L2 addresses care-plan/logistics; Administrative Manager approves any deliberate new coverage commitment; Billing handles claim issues. | |
| PO-122 — Confirm monthly DCMP claim readiness | Deterministically verify final BAR alignment/tier, allowed service date, applicable contact cadence, at least one actual non-respite GUIDE service with sufficient evidence, rendering actor/organization, prior claims, and no manufactured empty-month activity. | PMP §§2.9 and 3.1. | Reconcile BAR status, tier, cadence window, touchpoint completion, service evidence, month, and prior claims and produce a claim-ready or exception result. Suppress any claim whose only support is an empty-month activity created for billing or a contact record without a named service and person-specific result. | No when authoritative service/alignment/cadence evidence is complete; source owner corrects only a missing/conflicting prerequisite; Billing handles a true billability exception. | Software returns claim-ready, not-ready, or exact exception; Philippine L1 pursues administrative evidence; Billing and Revenue Cycle resolves only a disputed financial rule; original service performer corrects their own evidence. | |
| PO-123 — Prepare the monthly DCMP claim correctly | Construct the standalone claim from accepted MBI, dementia code, BAR tier/G-code, earliest supported service date, first-month rule, and participant billing identifiers; validate and transmit under the approved claim-release interface. | PMP §3.1, Exhibit 10, and Appendix K. | Prefill claim fields from the BAR and service record, identify the earliest supported date, validate code and date combinations, and surface missing evidence. | No for approved automatic claim transmission; Billing human for manual release/construction or exception. | Software builds/validates/transmits when approved; Billing and Revenue Cycle performs the narrow manual claim act or resolves exceptions; no clinician re-attests clean source facts. | |
| PO-124 — Prevent a duplicate DCMP claim in the same month | Check the claims ledger across draft/submitted/paid/corrected statuses for one patient-month DCMP and block overlapping claims despite tier or performer changes. | PMP §3.1 and Appendix K. | Check the claims ledger for patient-month duplicates before release and flag overlapping draft or submitted claims. | No for the duplicate control; Billing human only for a legitimate correction/replacement exception. | Software blocks; Billing and Revenue Cycle resolves the bounded exception. | |
| PO-125 — Prevent separate billing for PFS services included in the DCMP | Compare proposed PFS claims with the current CMS included-code list, alignment/effective dates, overlapping-model rules, and corrections; hold only exact possible duplicate-payment items. | PMP §§3.3-3.4 and Exhibit 7. | Compare proposed PFS claims with the current included-code list and aligned dates and hold a possible duplicate for review. | No for exact code/date matches; Billing human for disputed classification/correction; CMO only if the disputed source fact is genuinely clinical, not to bless routine coding. | Software checks; Billing and Revenue Cycle resolves coding/payment exceptions; CMO answers only an actual medical-service classification question. | |
| PO-126 — Reconcile DCMP claims, denials, recoupments, and payment reports | Match claims to remittance/BAR/payment data, classify denial/recoupment reasons, correct supported errors, decide appeal/repayment only under approved policy, and keep patient balances at zero. | Necessary delivery work supporting PMP §§3.1-3.3 and Appendix J. | Match claims to remittance and BAR data, classify discrepancies, and prepare a correction worklist. | Yes for nonstandard denial, appeal, recoupment, repayment, or payment dispute; no for matching/standard correction preparation. | Billing and Revenue Cycle performs the actual financial correction/dispute; Philippine L1 pursues missing source evidence; Healthcare Legal Counsel answers a genuine legal issue. The actual corporate authority handles any separately required material settlement approval; D-027 is not inferred to grant that power. The original clinical author corrects only an actual clinical source error. | |
| PO-127 — Keep CMS-calculated measures out of the participant-reporting queue | Maintain the current measure-source map and suppress participant submission work for CMS-calculated DAE, TPCC, and LTNH while routing published results to PO-097. | PMM §§2.1-2.3. | Maintain the measure-source map, suppress obsolete reporting tasks, and route available results to the performance review. | No under current authoritative rules; yes only for a changed PMM instruction. | Software enforces; Philippine L1/data-custodian capacity retrieves current guidance; Software Engineering corrects a confirmed implementation defect. | |
| PO-128 — Maintain QPP MIPS reporting separately from GUIDE reporting | Keep GUIDE reporting separate from QPP/MIPS: where the Participant/practitioner is MIPS-eligible, GUIDE submissions do not satisfy that independent obligation. Confirm the actual QPP reporting route, eligible population, attestors and existing accepted submission; do not duplicate it. This is outside the GUIDE care-delivery minimum and not optional when QPP independently requires it; Proxi's support scope and any separately retained practice act must be explicit. | PMM §1.5. | Maintain separate obligation calendars and measure inventories and flag an attempt to treat one submission as the other. | No for obligation separation and calendar control; yes for any required QPP clinician/organizational attestation or manual submit. | Software maintains separation; Billing and Revenue Cycle supports reporting administration; exact QPP attestor/submitter follows QPP authority and may be external/Participant-retained; Administrative Manager does not inherit QPP attestation authority by default. | |
| PO-129 — Maintain the CMS data request and attestation for participant data feeds | From the current PA/GUIDE Connect process, inventory requested CMS data, purpose, minimum-necessary basis, recipients, uses, selections, renewal/change, and exact attestation; prepare and transmit only after the controlling procedure is available. | RFA Data Sharing. Exact current form and operating instructions remain pending the Participation Agreement and GUIDE Connect. | Prepare the data inventory and request fields, compare requested uses with authorized operations, and track renewal or change. | Yes for the exact data-use/attestation authority the current procedure requires; no generic per-case privacy reviewer. | Software prepares the requested-data/purpose/recipient inventory; System Administrator enforces approved access/use configuration; Healthcare Legal Counsel answers only an uncovered legal-basis question. The exact required institutional attestor remains unassigned under O-PA-001 until the controlling procedure and individual capacity are known; an approved data custodian transmits after that act, not before. | |
| PO-129A — Explain and honor the beneficiary's claims-data-sharing preference | Using the current required notice/process, explain claims-data sharing, capture the beneficiary/authorized representative's preference and effective date without affecting care, route changes, and enforce the recorded preference across authorized data operations. | RFA Data Sharing. The current notice, form, timing, and process remain pending the Participation Agreement and GUIDE Connect instructions. | Prepare approved notice language, capture the choice and effective date, route a change request, and keep the preference visible to authorized data operations. | The beneficiary/representative supplies the choice; L2 human explanation only if required by the current process, requested, or comprehension remains uncertain; exact mode/confirmation remains open. | Software prepares/explains/enforces when approved; Puerto Rico L2 provides human explanation; Philippine L1 handles administrative request routing; System Administrator applies approved access configuration; Healthcare Legal Counsel handles a genuine authority question. | |
| PO-130 — Verify provider preference after a new pending-alignment notice | Within 15 days of the new pending-alignment notice, conduct a neutral direct conversation with the beneficiary/caregiver, confirm provider preference without influence, record the attributable response, and route unresolved authority/comprehension separately. | PMP §2.14. | Start the deadline, prepare neutral questions, document the direct conversation, and flag an unresolved preference. | Yes for the direct neutral confirmation under the current source; the beneficiary/caregiver makes the choice. | Puerto Rico L2 conducts the conversation; software starts the clock/prepares questions/records; Philippine L1 schedules/pursues; Healthcare Legal Counsel handles only a representative-authority dispute. | |
| PO-131 — Send care-transition information to the new participant within 15 days | Authenticate the new participant request, apply the approved permission/disclosure rule, assemble the exact current scoped transition packet from accepted products, deliver within 15 days through the approved route, and track receipt/unresolved needs. | PMP §2.14. | Assemble the authorized transition packet, calculate the deadline, check for missing current information, and track receipt. | No new clinician for current accepted content; one exact current V1 release act if required; L1 for endpoint/records failure; clinician only to create/update missing or changed clinical content. | Software assembles/tracks; Philippine L1 verifies endpoints/pursues records; exact approved release performer is governed by O-008/O-021/O-PA-001; original L3/L4 professional updates only necessary clinical substance; receiving participant performs its own receipt/use. | |
| PO-132 — Complete the receiving-participant side of a GUIDE transfer | Ask about current GUIDE participation, confirm the sending Participant was notified, request that documentation and coordinate the handoff. Complete the receiving Participant's full voluntary-alignment process, including consent before its required initial assessment and current attestations/submission. A previous Participant's assessment is not simply relabeled as the receiving GUIDE initial assessment; permitted written clinical source reports may still inform the new required product without repeating record gathering. | PMP §2.14. | Present the transfer intake, track required confirmations and records, and keep the case pre-alignment until the ordinary CMS process is complete. | Yes for the transfer relationship/consent discussions and each genuinely required source act; do not duplicate accepted clinical work unless the receiving process requires a new/current product. | Puerto Rico L2 handles transfer and consent discussions; Philippine L1 gathers records and may act in approved data-custodian capacity; software tracks/reuses accepted products; L3/L4 performs only required new clinical assessment/attestation; sending/receiving participants and beneficiary perform their own external/choice acts. |
Companion classification table#
The labels below are copied exactly from 17_GUIDE_Minimum_Value_and_Clinical_Work.md. They answer three independent questions: GUIDE standing, customer value, and clinical lane.
| Task | GUIDE standing | Customer value | Clinical lane |
|---|---|---|---|
| PO-001 — Open a potential-patient intake | Necessary delivery work | Value through better execution | No clinical judgment |
| PO-002 — Confirm the address is in the participant service area | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-003 — Confirm enrollment in Medicare Parts A and B | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-004 — Confirm Medicare is the primary payer | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-005 — Confirm the patient is not enrolled in Medicare Advantage, a Special Needs Plan, or PACE | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-006 — Confirm the patient has not elected the Medicare hospice benefit | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-007 — Confirm the patient is not aligned to another GUIDE participant | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-008 — Collect the facts needed to classify the residence | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-009 — Apply the PY 2026 eligible-residence rule | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-010 — Verify RCC approval and arrangement prerequisites during intake | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-011 — Identify whether dementia confirmation is still needed | Necessary delivery work | Core customer value | Clinical review on trigger |
| PO-012 — Explain GUIDE services and exclusive GUIDE care-delivery alignment | Public 2026 requirement | Core customer value | No clinical judgment |
| PO-013 — Explain voluntariness, freedom of choice, and the right to stop | Public 2026 requirement | Core customer value | No clinical judgment |
| PO-014 — Identify whose consent can be documented | Necessary delivery work | Core customer value | Clinical review on trigger |
| PO-015 — Obtain and document consent or refusal before the initial assessment | Public 2026 requirement | Core customer value | No clinical judgment |
| PO-016 — Stop the alignment workflow after refusal or absent consent | Public 2026 requirement | Core customer value | No clinical judgment |
| PO-017 — Schedule the initial comprehensive assessment after consent | Necessary delivery work | Value through better execution | No clinical judgment |
| PO-018 — Obtain the current PAAF and current completion instructions | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-019 — Collect and verify patient identifiers for the PAAF | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-020 — Collect caregiver identity and status for the PAAF | Public 2026 requirement | Core customer value | No clinical judgment |
| PO-021 — Collect the roster clinician information for the PAAF | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-022 — Administer and interpret the approved dementia-staging tool | Public 2026 requirement | Core customer value | Clinical judgment required |
| PO-023 — Administer PROMIS-10 at the initial assessment | Public 2026 requirement | Core customer value | Clinical review on trigger |
| PO-024 — Administer ZBI-22 when there is an identified caregiver | Public 2026 requirement | Core customer value | Clinical review on trigger |
| PO-025 — Assemble the dementia-diagnosis evidence for the attesting clinician | Necessary delivery work | Core customer value | No clinical judgment |
| PO-026 — Complete the dementia diagnosis attestation | Public 2026 requirement | Core customer value | Clinical judgment required |
| PO-027 — Complete the eligible-residence attestation | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-028 — Record residence type and RCC Partner ID | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-028A — Confirm the initial home-visit assessment is complete before PAAF submission | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-029 — Assemble the complete initial PAAF packet | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-030 — Check the PAAF for completeness, dates, and internal consistency | Necessary delivery work | Compliance infrastructure | No clinical judgment |
| PO-031 — Resolve missing or contradictory PAAF facts | Necessary delivery work | Value through better execution | Clinical review on trigger |
| PO-032 — Submit the initial PAAF within 60 days | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-033 — Retain the submitted PAAF and CMS receipt | Necessary delivery work | Compliance infrastructure | No clinical judgment |
| PO-034 — Retrieve the real-time preliminary alignment notification | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-035 — Work pending or rejected preliminary results | Necessary delivery work | Value through better execution | Clinical review on trigger |
| PO-036 — Retrieve the final Beneficiary Alignment Report result | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-037 — Reconcile the final alignment decision, tier, and effective date | Necessary delivery work | Compliance infrastructure | No clinical judgment |
| PO-038 — Wait for final CMS confirmation before ongoing GUIDE service activation or billing | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-039 — Send the aligned-patient notice within 45 days | Public 2026 requirement | Core customer value | No clinical judgment |
| PO-040 — Retain proof that the aligned-patient notice was provided | Necessary delivery work | Compliance infrastructure | No clinical judgment |
| PO-041 — Explain a non-alignment result and available next steps | Beyond the public GUIDE minimum | Core customer value | No clinical judgment |
| PO-042 — Calculate each annual-assessment window | Necessary delivery work | Compliance infrastructure | No clinical judgment |
| PO-043 — Schedule and start the annual assessment within days 306-425 | Public 2026 requirement | Core customer value | No clinical judgment |
| PO-044 — Collect the current annual PAAF data set | Public 2026 requirement | Core customer value | No clinical judgment |
| PO-045 — Renew the dementia attestation at the annual assessment | Public 2026 requirement | Core customer value | Clinical judgment required |
| PO-046 — Renew the eligible-residence attestation and RCC fields annually | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-047 — Submit the annual PAAF by the earlier deadline | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-048 — Reconcile the annual submission result and correct remediable errors | Necessary delivery work | Compliance infrastructure | Clinical review on trigger |
| PO-049 — Detect changes that may require a reassessment PAAF | Public 2026 requirement | Value through better execution | No clinical judgment |
| PO-050 — Submit an eligible-residence change reassessment on the permitted cadence | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-051 — Submit a dementia-severity change reassessment on the permitted cadence | Public 2026 requirement | Core customer value | Clinical judgment required |
| PO-052 — Submit a caregiver-status or burden reassessment on the permitted cadence | Public 2026 requirement | Core customer value | Clinical review on trigger |
| PO-053 — Keep reassessments separate from the annual requirement | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-054 — Maintain the required interdisciplinary care team | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-055 — Designate a trained human care navigator as primary contact | Public RFA care-delivery requirement | Core customer value | No clinical judgment |
| PO-056 — Maintain a dementia-proficient Part B E/M clinician | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-057 — Document the clinician's dementia-proficiency basis | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-058 — Appoint a physician medical director when required | Public RFA care-delivery requirement | Compliance infrastructure | No clinical judgment |
| PO-059 — Keep every team member within license and scope | Public RFA care-delivery requirement | Core customer value | No clinical judgment |
| PO-060 — Maintain the GUIDE Practitioner Roster | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-060A — Confirm GUIDE practitioner assignment and billing-rights prerequisites | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-061 — Maintain the Partner Organization Roster | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-062 — Maintain accurate service-area ZIP codes | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-063 — Maintain approved data custodians and CMS portal access | Necessary delivery work | Compliance infrastructure | No clinical judgment |
| PO-064 — Maintain qualifying CEHRT | Public RFA care-delivery requirement | Compliance infrastructure | No clinical judgment |
| PO-065 — Prevent patient cost-sharing for GUIDE services | Public 2026 requirement | Core customer value | No clinical judgment |
| PO-066 — Assign initial training when a navigator joins | Public RFA care-delivery requirement | Compliance infrastructure | No clinical judgment |
| PO-067 — Cover every required navigator-training topic | Public RFA care-delivery requirement | Value through better execution | Clinical review on trigger |
| PO-068 — Deliver at least 10 hours of didactic instruction | Public RFA care-delivery requirement | Compliance infrastructure | No clinical judgment |
| PO-069 — Deliver at least 10 hours of live experiential training | Public RFA care-delivery requirement | Value through better execution | Clinical review on trigger |
| PO-070 — Administer the navigator comprehension assessment | Public RFA care-delivery requirement | Compliance infrastructure | Clinical review on trigger |
| PO-071 — Provide at least two additional training hours each year | Public RFA care-delivery requirement | Value through better execution | No clinical judgment |
| PO-072 — Retain navigator qualification evidence | Necessary delivery work | Compliance infrastructure | No clinical judgment |
| PO-073 — Define what each partner organization will deliver | Necessary delivery work | Value through better execution | Clinical review on trigger |
| PO-074 — Execute a partner contract and payment arrangement before partner delivery | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-075 — Add and update partners on the CMS roster as changes occur | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-075A — Obtain CMS approval before any partner begins GUIDE delivery | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-075B — Oversee partner-delivered GUIDE work | Public 2026 requirement | Compliance infrastructure | Clinical review on trigger |
| PO-076 — Classify a congregate setting before treating it as an RCC | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-077 — Obtain CMS approval before adding an RCC partner | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-078 — Execute the enhanced RCC Partner Organization Arrangement | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-079 — Record and use the approved RCC Partner ID | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-080 — Monitor RCC approval and arrangement status over time | Necessary delivery work | Compliance infrastructure | No clinical judgment |
| PO-081 — Run the 60-day RCC transition when both approval and a compliant arrangement are absent | Public 2026 requirement | Core customer value | Clinical review on trigger |
| PO-082 — Run the 15-day transition for a move to a Memory Care Unit | Public 2026 requirement | Core customer value | Clinical review on trigger |
| PO-083 — Calendar the current care-delivery reporting window | Necessary delivery work | Compliance infrastructure | No clinical judgment |
| PO-084 — Gather the facts for care-delivery reporting | Public RFA care-delivery requirement | Compliance infrastructure | No clinical judgment |
| PO-085 — Validate and submit care-delivery reporting | Public RFA care-delivery requirement | Compliance infrastructure | Clinical review on trigger |
| PO-086 — Retain support for every care-delivery reporting response | Necessary delivery work | Compliance infrastructure | No clinical judgment |
| PO-087 — Maintain and annually update the Health Equity Plan | Public RFA care-delivery requirement | Value through better execution | Clinical review on trigger |
| PO-088 — Measure Health Equity Plan progress and adjust approved interventions | Public RFA care-delivery requirement | Value through better execution | Clinical review on trigger |
| PO-089 — Report Health Equity Plan progress annually | Public RFA care-delivery requirement | Compliance infrastructure | No clinical judgment |
| PO-090 — Ask willing aligned patients for required sociodemographic data | Public RFA care-delivery requirement | Core customer value | No clinical judgment |
| PO-091 — Ask willing aligned patients for required HRSN data | Public RFA care-delivery requirement | Core customer value | Clinical review on trigger |
| PO-092 — Aggregate and report annual sociodemographic and HRSN data | Public RFA care-delivery requirement | Compliance infrastructure | No clinical judgment |
| PO-093 — Maintain the participant-reported performance-data calendar | Necessary delivery work | Compliance infrastructure | No clinical judgment |
| PO-094 — Submit complete PROMIS-10 and applicable ZBI-22 performance data | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-095 — Reconcile performance-data coverage to the aligned population | Necessary delivery work | Compliance infrastructure | Clinical review on trigger |
| PO-096 — Follow the current PY 2026 high-risk-medication reporting rule | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-097 — Review quarterly DFT results and the annual PBA workbook | Beyond the public GUIDE minimum | Value through better execution | Clinical review on trigger |
| PO-098 — Correct remediable performance-data problems before the deadline | Necessary delivery work | Compliance infrastructure | Clinical review on trigger |
| PO-099 — Maintain the GUIDE audit file | Public RFA care-delivery requirement | Compliance infrastructure | No clinical judgment |
| PO-100 — Respond to CMS monitoring and audit requests | Public RFA care-delivery requirement | Compliance infrastructure | Clinical review on trigger |
| PO-101 — Cooperate with the independent GUIDE evaluation | Public 2026 requirement | Compliance infrastructure | Clinical review on trigger |
| PO-102 — Keep the Beneficiary Alignment Report reconciled | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-103 — Monitor Medicare coverage and payer changes | Necessary delivery work | Compliance infrastructure | No clinical judgment |
| PO-104 — Monitor hospice election, death, nursing-home residence, and prolonged inactivity | Necessary delivery work | Core customer value | Clinical review on trigger |
| PO-105 — Monitor residence and service-area changes | Public 2026 requirement | Core customer value | No clinical judgment |
| PO-106 — Act on evidence that the patient no longer has dementia | Public 2026 requirement | Core customer value | Clinical judgment required |
| PO-107 — Receive and document a request to stop GUIDE services | Public 2026 requirement | Core customer value | No clinical judgment |
| PO-108 — Submit stop-request unalignment within 15 business days | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-109 — Submit mandatory participant-reported ineligibility unalignment | Public 2026 requirement | Compliance infrastructure | Clinical review on trigger |
| PO-110 — Optionally report death, hospice election, or planned permanent nursing-home move | Beyond the public GUIDE minimum | Compliance infrastructure | No clinical judgment |
| PO-111 — Confirm the CMS unalignment result and effective date | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-112 — Send the required unalignment notice within 30 days | Public 2026 requirement | Core customer value | No clinical judgment |
| PO-113 — Retain proof of the unalignment notice or documented exception | Necessary delivery work | Compliance infrastructure | No clinical judgment |
| PO-114 — Cease GUIDE billing at the applicable unalignment date | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-115 — Limit transition-period service and billing to the permitted window | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-115A — Submit final GUIDE claims after Memory Care Unit unalignment within 30 days | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-116 — Coordinate continuity when GUIDE alignment ends | Necessary delivery work | Core customer value | Clinical review on trigger |
| PO-117 — Cooperate when the patient changes GUIDE participants | Public 2026 requirement | Core customer value | Clinical review on trigger |
| PO-118 — Close the internal GUIDE episode only after required work is complete | Necessary delivery work | Compliance infrastructure | No clinical judgment |
| PO-119 — Build and maintain the potential-patient referral network | Public 2026 requirement | Value through better execution | No clinical judgment |
| PO-120 — Conduct potential-patient outreach without coercion | Necessary delivery work | Core customer value | No clinical judgment |
| PO-121 — Document a temporary residence period | Public 2026 requirement | Core customer value | No clinical judgment |
| PO-122 — Confirm monthly DCMP claim readiness | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-123 — Prepare the monthly DCMP claim correctly | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-124 — Prevent a duplicate DCMP claim in the same month | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-125 — Prevent separate billing for PFS services included in the DCMP | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-126 — Reconcile DCMP claims, denials, recoupments, and payment reports | Necessary delivery work | Compliance infrastructure | No clinical judgment |
| PO-127 — Keep CMS-calculated measures out of the participant-reporting queue | Public 2026 requirement | Compliance infrastructure | No clinical judgment |
| PO-128 — Maintain QPP MIPS reporting separately from GUIDE reporting | Beyond the public GUIDE minimum | Compliance infrastructure | No clinical judgment |
| PO-129 — Maintain the CMS data request and attestation for participant data feeds | Public RFA care-delivery requirement | Compliance infrastructure | No clinical judgment |
| PO-129A — Explain and honor the beneficiary's claims-data-sharing preference | Public RFA care-delivery requirement | Core customer value | No clinical judgment |
| PO-130 — Verify provider preference after a new pending-alignment notice | Public 2026 requirement | Core customer value | No clinical judgment |
| PO-131 — Send care-transition information to the new participant within 15 days | Public 2026 requirement | Core customer value | No clinical judgment |
| PO-132 — Complete the receiving-participant side of a GUIDE transfer | Public 2026 requirement | Core customer value | Clinical review on trigger |
Coverage and row check#
- Main task rows: 138
- Companion classification rows: 138
- Tasks missing a companion row: 0
- Companion rows without a main task: 0
- Scope check: No respite-service delivery tasks are included.
- Source check still required: Executed PY 2026 Participation Agreement, contractual Appendix D, current GUIDE Connect instructions, current PAAF instructions, and current portal/roster manuals.