Status: Public-source working task breakdown
Date: 2026-07-11
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 built from the current public CMS materials available on 2026-07-11. It is not yet the final contractual inventory.
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 2026-05-22 (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 deliberately labeled as an operating step needed to produce or prove a required result, not as wording CMS expressly prescribed. A Beyond the public GUIDE minimum row is deliberately optional in the public materials.
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.
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 | Receive the referral, inquiry, or internal identification; record the patient, referrer, contact route, and reason GUIDE may fit; and distinguish a potential patient from a CMS-confirmed aligned patient. | 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. | Yes for referral acceptance and exceptions. | Enrollment or intake staff; care navigator when the relationship has already begun. | |
| PO-002 — Confirm the address is in the participant service area | Verify the current residence ZIP code against the participant's submitted service area and confirm the organization can furnish all required GUIDE care-delivery services there. | PMP §1.4.3; FAQ Q7. | Compare the address with the current approved ZIP list and flag mismatches or incomplete addresses. | No for a clean match; yes for exceptions. | Program operations or enrollment staff. | |
| PO-003 — Confirm enrollment in Medicare Parts A and B | Use an authoritative eligibility source to verify that both Part A and Part B are active for the relevant date; do not rely only on patient recollection. | PMP §2.4; FAQ Q4. | Retrieve or ingest the authorized eligibility response, compare dates, and flag absent or conflicting coverage. | No for the factual check; yes to resolve a discrepancy. | Enrollment staff or data custodian. | |
| PO-004 — Confirm Medicare is the primary payer | Verify Medicare-primary status for the relevant date and distinguish allowed secondary coverage from a situation in which Medicare is not primary. | PMP §2.4; FAQ Q4. | Compare available payer-order data and surface uncertainty for review. | No for a clear authoritative result; yes for an exception. | Enrollment or billing eligibility staff. | |
| PO-005 — Confirm the patient is not enrolled in Medicare Advantage, a Special Needs Plan, or PACE | Check current plan enrollment and effective dates; a future change must be treated separately from current eligibility. | PMP §2.4; FAQ Q4. | Read authorized coverage data, compare effective dates, and flag disqualifying enrollment. | No for a clear result; yes for an exception. | Enrollment or billing eligibility staff. | |
| PO-006 — Confirm the patient has not elected the Medicare hospice benefit | Verify current hospice election status before alignment and route any conflicting clinical or claims information for resolution. | PMP §2.4; FAQ Q4. | Compare authorized claims or eligibility data with the record and flag a possible election. | Yes when the available sources conflict. | Enrollment staff; clinician or billing specialist on exception. | |
| PO-007 — Confirm the patient is not aligned to another GUIDE participant | Check the CMS alignment result or other authorized CMS source and do not promise alignment when another GUIDE participant currently holds the 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 the check; yes to coordinate a transfer. | Data custodian or program operations. | |
| PO-008 — Collect the facts needed to classify the residence | Record whether the person lives in a private residence, an RCC, a Memory Care Unit, a long-term nursing home, or another setting; capture move dates and the specific building, unit, or bed type when relevant. | PMP §§2.4 and 2.12; FAQ Q4 and Q8. | Ask structured questions, normalize facility names and addresses, and flag ambiguous setting descriptions. | Yes for ambiguous or changing living arrangements. | Enrollment staff or care navigator; compliance lead on classification exceptions. | |
| PO-009 — Apply the PY 2026 eligible-residence rule | Treat a private residence or a CMS-approved RCC with a compliant arrangement as potentially eligible; do not treat a long-term nursing-home residence or Memory Care Unit as eligible. | 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. | Yes for final participant attestation or disputed classification. | Program operations or compliance staff. | |
| PO-010 — Verify RCC approval and arrangement prerequisites during intake | For an RCC resident, confirm the RCC is on the participant's CMS-approved Partner Organization Roster, a compliant Partner Organization Arrangement is in force, and the current RCC Partner ID is available. | 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. | Yes for agreement and approval confirmation. | Contracting, compliance, or program operations. | |
| PO-011 — Identify whether dementia confirmation is still needed | Separate an established dementia diagnosis from suspected dementia or mild cognitive impairment. L0/L1 first collects and organizes all available diagnosis evidence, source practitioner, date, gaps, and conflicts; missing records remain an administrative pursuit. The dementia-proficient clinician receives the completed or explicitly incomplete packet only to determine whether the evidence supports the required clinical attestation or is clinically insufficient. | 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. | Yes, for the clinical attestation judgment only. | L0/L1 preparation and record pursuit; dementia-proficient practitioner on the GUIDE Practitioner Roster for the protected judgment. | |
| PO-012 — Explain GUIDE services and exclusive GUIDE care-delivery alignment | Before consent, explain the model and the services available and state that GUIDE care-delivery services can be received from only one GUIDE participant at a time. | PMP §2.5 and Appendix G; FAQ Q5. | Prepare and present approved plain-language material, support language access, and record the topics covered. | Yes; this is a human conversation and patient choice. | Trained enrollment or care-team staff. | |
| PO-013 — Explain voluntariness, freedom of choice, and the right to stop | Tell the patient or caregiver that participation is voluntary, they may stop GUIDE services at any time, and alignment does not restrict Medicare care from other providers or suppliers. | PMP Appendix G; FAQ Q5-Q6. | Deliver approved wording, check understanding, and document questions without pressuring the decision. | Yes. | Trained enrollment or care-team staff. | |
| PO-014 — Identify whose consent can be documented | Identify the patient and, when applicable, caregiver or authorized representative involved in consent; verify identity and authority and route uncertainty about capacity or representative status before relying on the consent. | 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. | Yes. | Enrollment staff; clinician and compliance or legal owner on trigger; patient, caregiver, or authorized representative makes the choice. | |
| PO-015 — Obtain and document consent or refusal before the initial assessment | Complete the GUIDE discussion, obtain the patient's and/or caregiver's voluntary consent or refusal, and place the discussion and outcome in the medical record before the initial comprehensive assessment. The CMS Appendix G form is optional, not mandatory. | 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. | Yes. | Patient and/or caregiver or authorized representative; trained enrollment or care-team staff witnesses and documents. | |
| PO-016 — Stop the alignment workflow after refusal or absent consent | Do not perform the GUIDE initial comprehensive assessment as an alignment step and do not submit an alignment PAAF when consent was refused or has not been documented; record how the person may recontact the program. | PMP §2.5 and Appendix G. | Block preparation of an alignment packet when the consent evidence is absent and generate a respectful follow-up record. | Yes for communication; no for the routine hold. | Enrollment staff or program operations. | |
| PO-017 — Schedule the initial comprehensive assessment after consent | Arrange the assessment with the patient and caregiver as applicable, using their modality preference where allowed, and give the assessment team the verified intake and consent information. | PMP §2.5; FAQ Q6 and Q13. | Offer times, send reminders, assemble the pre-visit packet, and flag accessibility or caregiver-participation needs. | Yes for the assessment and unresolved logistics. | Scheduling staff and interdisciplinary care team. | |
| PO-018 — Obtain the current PAAF and current completion instructions | Download the current submission template directly from HDR in the CMS ePortal and use the field definitions, accepted route, and CMS instructions current for the submission date. The GUIDE Connect template is reference-only; do not submit an old or remembered version. | 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. | Yes to confirm the current CMS materials. | Data custodian or GUIDE portal administrator. | |
| PO-019 — Collect and verify patient identifiers for the PAAF | Capture the legal name, MBI, date of birth, and other current PAAF patient fields exactly as required; resolve transpositions and identity mismatches before submission. | PMP §2.7.2 and Exhibit 6. | Prefill from authorized sources, validate format, and compare identifiers across records. | No for a clean match; yes for mismatches. | Enrollment staff or data custodian. | |
| PO-020 — Collect caregiver identity and status for the PAAF | Determine whether the patient has a primary caregiver under GUIDE, record the required caregiver information and relationship, and distinguish no caregiver from missing caregiver data. | PMP §§2.1, 2.5, and Exhibit 6; PMM §2.2. | Ask the structured questions, prefill known data, and flag ambiguous unpaid-caregiver status. | Yes for the factual confirmation. | Assessment team or care navigator; patient and caregiver provide the facts. | |
| PO-021 — Collect the roster clinician information for the PAAF | Record the clinician identity and other current PAAF fields and confirm that the clinician who will attest is on the participant's current GUIDE Practitioner Roster. | PMP §2.6 and Exhibit 6. | Prefill roster data and flag an NPI or roster mismatch. | No for a clean match; yes to resolve a mismatch. | Data custodian and credentialing or roster owner. | |
| PO-022 — Administer and interpret the approved dementia-staging tool | Use CDR or FAST during the initial comprehensive assessment, record the score, and use the administration date as the PAAF assessment date. Qualified clinical interpretation stays with the care team. | 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. | Appropriate interdisciplinary care-team member within scope; dementia-proficient clinician for interpretation. | |
| PO-023 — Administer PROMIS-10 at the initial assessment | Collect every required PROMIS v1.2 Global Health response and required supplemental item using the current PAAF instructions; treat concerning answers as care issues, not merely reporting data. | PMP §2.5; PMM §§2.1-2.2. | Present the instrument, validate completion, score configured fields if allowed, and flag concerning or missing responses. | Yes for the patient response and any clinical trigger. | Patient; trained assessment staff; clinician on trigger. | |
| PO-024 — Administer ZBI-22 when there is an identified caregiver | Collect all required caregiver responses and supplemental items; do not omit the instrument when a primary caregiver exists and do not invent a caregiver when none exists. | 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. | Yes for the caregiver response and clinical or support trigger. | Primary caregiver; trained assessment staff; clinician or navigator on trigger. | |
| PO-025 — Assemble the dementia-diagnosis evidence for the attesting clinician | Place the relevant comprehensive-assessment findings or an acceptable written report from another Medicare-enrolled practitioner in front of the roster clinician; identify the source and do not convert a code alone into the attestation. | PMP §2.6. | Retrieve records, extract the diagnosis source and date, and mark missing or conflicting evidence. | Yes. | Clinical support staff and dementia-proficient practitioner. | |
| PO-026 — Complete the dementia diagnosis attestation | A dementia-proficient practitioner on the participant's Practitioner Roster attests that the patient meets the applicable dementia diagnostic guidelines based on the assessment or an acceptable written report; mild cognitive impairment alone is insufficient. | PMP §§2.4 and 2.6; FAQ Q4. | Prepare the evidence summary and PAAF field, but never make or sign the diagnosis attestation. | Yes. | Dementia-proficient practitioner on the GUIDE Practitioner Roster. | |
| PO-027 — Complete the eligible-residence attestation | The participant attests in the PAAF that the patient resides in an eligible residence type based on verified current facts and the PY 2026 rule. | PMP §§2.4 and 2.7; Exhibit 6. | Assemble address, setting type, RCC approval, and arrangement evidence and draft the attestation record. | Yes. | Authorized participant representative, usually program operations or compliance. | |
| PO-028 — Record residence type and RCC Partner ID | Enter the exact current residence type and, for an RCC resident, the applicable Partner ID from the Participant Portal; make sure these fields agree with the residence attestation. | 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 for an inconsistency. | Data custodian or program operations. | |
| PO-028A — Confirm the initial home-visit assessment is complete before PAAF submission | Confirm that the applicable required in-person or permitted remote home-visit assessment has been completed and that its current PAAF information is available before releasing the initial submission. This task confirms completion; the literal home-visit service remains in the Comprehensive Assessment SOP. | 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. | Yes for the visit and any exception; no for a clean completion check. | Interdisciplinary care-team member performs the visit; data custodian and program operations confirm the submission fact. | |
| PO-029 — Assemble the complete initial PAAF packet | Combine the patient, caregiver, clinician, attestation, residence, staging, PROMIS-10, ZBI-22, and other current required fields into the accepted CMS submission format. | 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. | Yes for final submission responsibility. | Data custodian; assessment and clinical owners supply and verify their fields. | |
| PO-030 — Check the PAAF for completeness, dates, and internal consistency | Confirm every conditional field is present, the assessment date equals the staging-tool date, consent predates the assessment, the form is within its submission window, and related clinical and residence fields agree. | Necessary control supporting PMP §§2.5-2.7. | Run deterministic completeness and consistency checks and produce a precise correction list. | Yes for exceptions and final release. | Data custodian; clinical owner for clinical conflicts. | |
| PO-031 — Resolve missing or contradictory PAAF facts | Return each problem to the actual source owner; correct factual errors with evidence and send diagnosis, staging, safety, or other clinical contradictions to the responsible clinician rather than guessing. | Necessary delivery work for a valid PMP §2.7 submission. | Route each discrepancy, track its owner, and refresh the packet after an authorized correction. | Yes. | Data custodian; enrollment, clinical, or compliance owner according to the fact. | |
| PO-032 — Submit the initial PAAF within 60 days | The data custodian submits the completed PAAF through HDR or another currently approved CMS route within 60 days after the dementia-staging assessment date. | PMP §2.7.1; PMM §2.2. | Prepare the upload, check the deadline, and support an authorized submission while preserving the exact submitted content. | Yes for the CMS submission. | Approved GUIDE data custodian. | |
| PO-033 — Retain the submitted PAAF and CMS receipt | Preserve the exact submitted data, submission timestamp, submitting custodian, CMS response, and source evidence needed to reconstruct the submission. | 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 routine capture; yes if the acknowledgment is missing. | Data custodian or compliance records owner. | |
| PO-034 — Retrieve the real-time preliminary alignment notification | After submission, retrieve the Real-time Beneficiary Alignment Notification Report and distinguish preliminary aligned from pending further review; use it only for the purposes CMS permits. | PMP §2.7.2 and Appendix I. | Import the report, match it to the submission, and summarize the preliminary status and stated reason. | No for retrieval; yes for action on an exception. | Data custodian and program operations. | |
| PO-035 — Work pending or rejected preliminary results | Read the CMS reason, determine whether the issue is a correctable data problem, an eligibility problem, or a CMS review, and send it to the correct owner without telling the patient 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. | Yes. | Data custodian; program operations; clinician for clinical facts. | |
| PO-036 — Retrieve the final Beneficiary Alignment Report result | Monitor eDFR for CMS's final eligibility and alignment decision, which the PMP says CMS communicates within 15 business days after receiving the PAAF; do not leave a preliminary result unresolved. | 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 for retrieval; yes for overdue or unmatched results. | Data custodian or program operations. | |
| PO-037 — Reconcile the final alignment decision, tier, and effective date | Record whether the patient is aligned or ineligible, the assigned tier when aligned, and the applicable effective date; compare the final BAR with the PAAF, internal roster, and planned care. | PMP §§2.7.2, 2.8, and Appendix H. | Match records, detect a changed tier or status, and create the operational handoff. | Yes for discrepancies and activation. | Program operations and data custodian; clinician only for disputed clinical facts. | |
| PO-038 — Wait for final CMS confirmation before ongoing GUIDE service activation or billing | Use the preliminary real-time notification only for CMS-permitted internal care-planning work. Except for the specified pre-alignment assessment/alignment work, wait until the patient appears as aligned in the final BAR before furnishing ongoing GUIDE care-delivery services or submitting the initial comprehensive-assessment claim or other GUIDE billing. | 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. | Yes for service activation, billing release, and status communication. | Program operations, data custodian, service owner, and billing owner. | |
| PO-039 — Send the aligned-patient notice within 45 days | Provide each CMS-confirmed eligible and aligned patient written notice using the CMS template in PMP Appendix D within 45 days after receiving the final decision in the BAR, through an allowed delivery channel. | PMP §2.7.3 and Appendix D. | Populate the current CMS template, calculate the deadline, prepare accessible delivery, and track completion. | Yes for release and patient communication. | Enrollment or program operations staff. | |
| PO-040 — Retain proof that the aligned-patient notice was provided | Keep the exact notice, final BAR date, delivery date and channel, destination, and any failed-delivery or follow-up record. | Necessary evidence for PMP §2.7.3. | Archive the notice and delivery evidence and flag an approaching or missed 45-day deadline. | No for routine capture; yes for failed delivery. | Program operations or compliance records owner. | |
| PO-041 — Explain a non-alignment result and available next steps | Tell the patient or caregiver that CMS did not align the patient, explain the stated reason in plain language without changing it, and describe legitimate next steps. CMS says the Appendix E non-alignment letter may be used but does not require it. | 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. | Yes. | Enrollment or program operations; clinician when the disputed fact is clinical. | |
| PO-042 — Calculate each annual-assessment window | Use the previous comprehensive-assessment date to calculate days 306 through 425, plus the earlier submission deadline of 60 days after the annual assessment starts or day 425. | PMP §2.11. | Calculate and display the opening date, last safe start date, and final submission deadline. | No for routine calculation; yes for disputed prior dates. | Program operations or data custodian. | |
| PO-043 — Schedule and start the annual assessment within days 306-425 | Arrange the patient and caregiver assessment so that it begins within the CMS window and leaves enough time to complete clinical work and submit before the earlier deadline. | PMP §2.11. | Generate due lists, schedule appointments, issue reminders, and flag cases at risk of missing the window. | Yes for the assessment and scheduling exceptions. | Scheduling staff and interdisciplinary care team. | |
| PO-044 — Collect the current annual PAAF data set | At the annual comprehensive assessment, collect the current required patient, caregiver, clinician, dementia, residence, staging, PROMIS-10, ZBI-22 when applicable, and supplemental fields using the current PAAF. | 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. | Yes. | Interdisciplinary assessment team, patient, caregiver, and data custodian. | |
| PO-045 — Renew the dementia attestation at the annual assessment | Have a rostered dementia-proficient practitioner review the current clinical evidence and complete the dementia attestation included in the annual PAAF. | PMP Exhibit 6 and §2.11. | Prepare the updated evidence and attestation field, but do not make or sign the clinical judgment. | Yes. | Dementia-proficient practitioner on the GUIDE Practitioner Roster. | |
| PO-046 — Renew the eligible-residence attestation and RCC fields annually | Verify the current residence, complete the eligible-residence attestation, and update the residence type and RCC Partner ID when applicable. | PMP Exhibit 6 and §2.11. | Compare the current address and RCC roster with the prior record and flag any move or expired arrangement. | Yes for the attestation and exceptions. | Program operations or compliance; data custodian. | |
| PO-047 — Submit the annual PAAF by the earlier deadline | Submit through the current approved CMS route by the earlier of 60 days after the annual assessment begins or day 425 after the previous comprehensive assessment. | PMP §2.11; PMM §2.2. | Assemble the approved packet, calculate the controlling deadline, and support the authorized submission. | Yes for submission. | Approved GUIDE data custodian. | |
| PO-048 — Reconcile the annual submission result and correct remediable errors | Retain the submitted annual PAAF and CMS response, correct permitted data errors promptly, and make sure the annual result is reflected in the current alignment and tier record. | Necessary handling supporting PMP §2.11. | Match the response, identify rejections or tier changes, and route each correction. | Yes for correction and release. | Data custodian and program operations; clinician for clinical corrections. | |
| PO-049 — Detect changes that may require a reassessment PAAF | During ongoing work, identify a change in residence type, dementia severity, caregiver status, or caregiver burden that may affect tiering, payment, or eligibility outside the annual cycle. | PMP §2.10; PMM §2.2 footnote 13. | Compare new structured facts with the last accepted PAAF and alert the responsible owner. | Yes to confirm clinical or ambiguous changes. | Care navigator and program operations; clinician for dementia-severity change. | |
| PO-050 — Submit an eligible-residence change reassessment on the permitted cadence | Verify the new residence, complete the required residence and attestation fields, include an RCC Partner ID when applicable, and submit no more frequently than the current 30-day cadence. | PMP §2.10 and Exhibit 6. | Prepare the residence-change packet, enforce the cadence, and flag RCC or ineligible-setting issues. | Yes for attestation and submission. | Program operations or compliance and data custodian. | |
| PO-051 — Submit a dementia-severity change reassessment on the permitted cadence | Have an appropriate clinician assess and document the changed stage, update the staging score and dementia attestation, and submit no more frequently than the current 180-day cadence. | PMP §2.10 and Exhibit 6. | Collect the new tool responses, calculate the configured score, prepare the changed fields, and enforce the cadence. | Yes. | Appropriate clinical assessor, dementia-proficient practitioner, and data custodian. | |
| PO-052 — Submit a caregiver-status or burden reassessment on the permitted cadence | When caregiver status or burden changes, verify the caregiver facts, administer and submit the ZBI-22 when required, and use the current 180-day cadence. | 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. | Yes for caregiver response and triggered support. | Caregiver, trained assessment staff, care navigator, and data custodian. | |
| PO-053 — Keep reassessments separate from the annual requirement | Do not treat a residence, dementia, or caregiver reassessment as satisfying the annual comprehensive assessment; preserve the annual due date and reconcile any CMS tier change separately. | 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 for a disputed CMS result. | Program operations or data custodian. | |
| PO-054 — Maintain the required interdisciplinary care team | Keep an operational team capable of delivering the required GUIDE services, with at least the required human care navigator and dementia-proficient clinician and additional disciplines as needed. | RFA Participation Requirements and Care Team Requirements. | Maintain the staff directory, coverage view, qualification evidence, and vacancy alerts. | Yes. | GUIDE program director and clinical leader. | |
| PO-055 — Designate a trained human care navigator as primary contact | Assign an individual, not artificial intelligence, who has completed GUIDE training and serves as the patient's and caregiver's primary point of contact. | 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. | Yes. | Trained human care navigator; program manager assigns. | |
| PO-056 — Maintain a dementia-proficient Part B E/M clinician | Keep at least one clinician who meets GUIDE dementia-proficiency criteria, is eligible to bill Medicare Part B E/M services, and can perform the required clinical work and attestations. | RFA Care Team Requirements. | Track roster status, credentials, qualification evidence, and coverage gaps. | Yes. | Credentialing owner, clinical leader, and qualifying physician, NP, PA, or CNS. | |
| PO-057 — Document the clinician's dementia-proficiency basis | Retain the applicable patient-panel attestation or qualifying specialty evidence and make sure the proof remains tied to the clinician on the current Practitioner Roster. | RFA Care Team Requirements. | Collect the evidence, test completeness, and alert before a qualification or roster gap affects care. | Yes for attestation. | Qualifying clinician and credentialing or compliance staff. | |
| PO-058 — Appoint a physician medical director when required | If the dementia-proficient clinician is not a physician, maintain an additional part-time physician medical director who oversees quality of care for the dementia care program. | RFA Care Team Requirements. | Detect when the condition applies and maintain appointment and coverage evidence. | Yes. | GUIDE executive or program director and physician medical director. | |
| PO-059 — Keep every team member within license and scope | Assign assessment, clinical, navigation, education, and administrative work only to people permitted and competent to perform it; route medical complexity from non-clinical navigators to clinical team members. | RFA Appendix B §§1.1.3.2 and 4.2.1. | Show role boundaries, flag out-of-scope assignments, and route triggered clinical questions. | Yes. | Clinical leader, program manager, and each licensed professional. | |
| PO-060 — Maintain the GUIDE Practitioner Roster | Add, update, and remove practitioners so the CMS roster accurately reflects the people performing GUIDE practitioner functions; verify NPI and current relationship before relying on the roster. | RFA Participation Requirements; PMP §2.6. | Compare credentialing data with the CMS roster and produce additions, removals, and mismatches for authorized submission. | Yes for CMS roster changes. | Credentialing or roster administrator and data custodian. | |
| PO-060A — Confirm GUIDE practitioner assignment and billing-rights prerequisites | Before relying on a practitioner for GUIDE billing, confirm the practitioner accepts Medicare assignment and has reassigned the applicable billing rights to the participant TIN for the relevant service period. | 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. | Yes for credentialing and billing release. | Credentialing, enrollment, billing compliance, and the practitioner. | |
| PO-061 — Maintain the Partner Organization Roster | Keep every partner organization and required identifying information current and remove organizations that no longer have a valid role or arrangement. | RFA Participation Requirements; FAQ Q14. | Compare active contracts and service assignments with the CMS roster and flag stale or missing partners. | Yes for CMS roster changes. | Contracting, compliance, or roster administrator. | |
| PO-062 — Maintain accurate service-area ZIP codes | Add or remove ZIP codes in the Participant Portal as appropriate and retain the complete downloaded list, recognizing that only the first 250 may be visible in the portal. | PMP §1.4.3. | Compare actual operations with the CMS list, identify gaps, and prepare the authorized update. | Yes for the service-area decision and portal submission. | GUIDE program operations or portal administrator. | |
| PO-063 — Maintain approved data custodians and CMS portal access | Keep enough authorized data custodians and portal users to submit PAAFs, retrieve HDR and eDFR results, and maintain continuity when staff change; remove access that is no longer appropriate. | 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. | CMS portal administrator, security owner, and GUIDE program director. | |
| PO-064 — Maintain qualifying CEHRT | Use and maintain an electronic health record platform meeting CMS and ONC Certified Electronic Health Record Technology requirements for GUIDE participation. | RFA Participation Requirements. | Track attestation and vendor evidence, surface expiring or missing certification support, and prepare audit documentation. | Yes. | Health IT leader, compliance owner, and GUIDE program director. | |
| PO-065 — Prevent patient cost-sharing for GUIDE services | Ensure aligned patients are not charged any amount for GUIDE services and that statements, collections, and partner practices do not create prohibited patient cost-sharing. | Current FAQ Q11. | Check GUIDE charges and patient statements, flag a patient balance, and prepare correction and refund work. | Yes for financial correction and oversight. | Billing compliance, finance, and program operations. | |
| PO-066 — Assign initial training when a navigator joins | Require the one-time GUIDE navigator training when an individual joins the care team, regardless of professional background, before the person independently performs the navigator role. | RFA Care Navigator Training. | Enroll the navigator, calculate due dates, and prevent an incomplete training record from being treated as qualified. | Yes. | Training lead and GUIDE program manager. | |
| PO-067 — Cover every required navigator-training topic | The curriculum must address dementia, assessments, care plans, person-centered planning, challenging behaviors, functional needs, advance care planning, decision-making capacity, safety, communication, coordination, caregiver support, and diversity in dementia. | RFA Care Navigator Training, Table 4. | Map course content to the required topics, identify coverage gaps, and maintain an auditable curriculum crosswalk. | Yes for content approval and instruction. | Training lead with clinical educator and subject-matter owners. | |
| PO-068 — Deliver at least 10 hours of didactic instruction | Provide at least 10 didactic hours within the minimum 20-hour initial program; the didactic portion may be live or web-based. | RFA Care Navigator Training. | Schedule content, track attendance and completed time, and flag a shortfall. | Yes for instruction and oversight. | Training lead and instructors. | |
| PO-069 — Deliver at least 10 hours of live experiential training | Provide at least 10 live, non-asynchronous experiential hours through supervised interactions, shadowing, case studies, on-the-job training, or another accepted live method. | RFA Care Navigator Training. | Schedule supervised experiences, capture supervisor verification, and total eligible live hours. | Yes. | Qualified supervisor, experienced navigator, clinical educator, or training lead. | |
| PO-070 — Administer the navigator comprehension assessment | Give each navigator the participant-developed post-training assessment required to ensure comprehension and address any failed or incomplete areas before qualification. | RFA Care Navigator Training. | Deliver and score the approved assessment, report missed domains, and track remediation. | Yes for assessment approval and remediation decisions. | Training lead; clinical educator for clinical domains. | |
| PO-071 — Provide at least two additional training hours each year | Assign and document at least two hours of annual training for every active care navigator, using participant-developed or qualifying third-party continuing education. | RFA Care Navigator Training. | Maintain the annual due list, recommend approved offerings, and track completion. | Yes for training delivery or approval. | Training lead and GUIDE program manager. | |
| PO-072 — Retain navigator qualification evidence | Keep the curriculum, topic coverage, didactic and experiential hours, attendance, supervisor verification, comprehension result, remediation, and annual training record for each navigator. | 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 record assembly; yes for qualification approval. | Training administrator, program manager, and compliance records owner. | |
| PO-073 — Define what each partner organization will deliver | Specify the GUIDE work, population, location, staffing, handoff, documentation, and accountability assigned to each partner so required participant duties are not left between organizations. | 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. | GUIDE program director, contracting, clinical leader, and partner owner. | |
| PO-074 — Execute a partner contract and payment arrangement before partner delivery | Put a contract in place that reflects the agreed payment arrangement and the partner's GUIDE responsibilities before relying on the organization to furnish GUIDE services. | Current FAQ Q14. | Track required agreement elements, signatures, effective dates, and service start dependencies. | Yes. | Contracting, finance, compliance, and authorized signatories. | |
| PO-075 — Add and update partners on the CMS roster as changes occur | Submit required partner information to CMS, keep the Partner Organization Roster synchronized with active arrangements, and stop treating a removed or unapproved organization as a GUIDE partner. | Current FAQ Q14; RFA Participation Requirements. | Compare contracts with the CMS roster and prepare the authorized update and evidence. | Yes. | Partner roster administrator, contracting, and compliance. | |
| PO-075A — Obtain CMS approval before any partner begins GUIDE delivery | Do not allow a Partner Organization to furnish GUIDE care-delivery services until CMS has approved its participation and it is active for the applicable service date. | 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. | Yes for approval confirmation and service release. | Partner roster administrator, contracting, compliance, and GUIDE program operations. | |
| PO-075B — Oversee partner-delivered GUIDE work | Confirm that each partner performs the assigned GUIDE work, supplies the records and service dates the participant needs, follows the approved arrangement, and is paid according to the agreement; the participant remains responsible for meeting model requirements. | 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. | GUIDE program director, partner owner, clinical or service owner, contracting, and finance. | |
| PO-076 — Classify a congregate setting before treating it as an RCC | Determine whether the setting fits the current RCC description or is instead a Memory Care Unit, nursing-home level setting, private residence, or another category; examine the actual unit or bed type when needed. | 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. | Yes for ambiguous cases. | Program operations or compliance; facility representative supplies facts. | |
| PO-077 — Obtain CMS approval before adding an RCC partner | Submit the RCC for CMS review and receive approval before adding it as an RCC Partner and before aligning or providing GUIDE services to patients residing there, subject to the transition rule for already aligned movers. | 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. | Yes. | Contracting, compliance, roster administrator, and authorized CMS submitter. | |
| PO-078 — Execute the enhanced RCC Partner Organization Arrangement | Have the fully executed compliant RCC arrangement in force before aligning an RCC resident or providing GUIDE services there; the undisclosed PY 2026 Participation Agreement §3.06 controls the exact enhanced terms. | PMP §2.8.1; current FAQ Q14. | Track the current CMS-required provisions, signatures, dates, and approval dependency without supplying legal approval. | Yes. | Legal or contracting counsel, compliance, RCC signatory, and participant signatory. | |
| PO-079 — Record and use the approved RCC Partner ID | Use the Partner ID assigned through the Participant Portal in the patient's PAAF and keep the ID tied to the correct approved RCC and arrangement. | 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 for correction. | Data custodian and RCC roster administrator. | |
| PO-080 — Monitor RCC approval and arrangement status over time | Track termination, expiration, material change, loss of approval, or a patient move to a different unit so an RCC prerequisite does not silently become invalid. | 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. | Yes for the disposition and agreement decision. | Contracting, compliance, program operations, and care navigator. | |
| PO-081 — Run the 60-day transition for a move to an unapproved or uncontracted RCC | From awareness of the move, use the 60-day period to obtain CMS approval and a compliant arrangement; if that cannot be done, coordinate care transition, assist planning, and submit an unalignment PAAF. | PMP §2.12. | Start the deadline, assemble approval and agreement work, issue reminders, and prepare the required unalignment and transition record if unresolved. | Yes. | Care navigator, contracting, compliance, data custodian, and program director. | |
| PO-082 — Run the 15-day transition for a move to a Memory Care Unit | From awareness of the move, coordinate the patient's care transition, assist transition planning, and submit the unalignment PAAF within the applicable 15-day transition period. | PMP §2.12; current FAQ Q8. | Start the deadline, prepare the transition checklist and PAAF, and track completion. | Yes. | Care navigator, program operations, data custodian, and clinical team on trigger. | |
| PO-083 — Calendar the current care-delivery reporting window | Obtain the current CMS reporting instructions and deadline for the participant's track and performance year; do not assume that the historical baseline dates remain the live dates. | 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. | Yes to confirm the current CMS instruction. | GUIDE program operations or quality lead. | |
| PO-084 — Gather the facts for care-delivery reporting | Collect how the participant implements each required service, contact frequency, modalities, staffing, partner delivery, and other current CMS questions from the actual operating records. | RFA Care Delivery Reporting; current FAQ Q17. | Aggregate records, draft factual answers, and identify unsupported or contradictory claims. | Yes for source confirmation. | Program operations, quality lead, service owners, and data owners. | |
| PO-085 — Validate and submit care-delivery reporting | Have accountable owners verify the report against actual practice, correct unsupported statements, and submit at least annually on the current CMS schedule. | RFA Care Delivery Reporting. | Run completeness checks, preserve approvals, and support the authorized CMS submission. | Yes. | GUIDE program director, quality lead, compliance, and authorized submitter. | |
| PO-086 — Retain support for every care-delivery reporting response | Keep the source reports, calculations, policies, samples, and owner approvals that substantiate each CMS answer and reporting period. | 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 assembly; yes for evidentiary judgment. | Quality lead and compliance records owner. | |
| PO-087 — Maintain and annually update the Health Equity Plan | Keep a comprehensive plan that identifies disparities, the population and measures used, goals, selected interventions, responsible owners, and the current implementation approach. | RFA Health Equity Plan Requirement. | Assemble the plan from approved analyses and actions, track owners and updates, and show missing evidence. | Yes. | Health equity lead, GUIDE program director, quality lead, and community or clinical owners. | |
| PO-088 — Measure Health Equity Plan progress and adjust approved interventions | Monitor the plan's stated measures, compare results with goals, document implementation, and have accountable owners select or revise evidence-based interventions without prohibited discriminatory targeting. | RFA Health Equity Plan Requirement. | Calculate approved measures, summarize progress, and surface disparities or weak implementation for human action. | Yes. | Health equity lead, quality analyst, compliance, and clinical or community owners. | |
| PO-089 — Report Health Equity Plan progress annually | Complete the Health Equity Plan section of care-delivery reporting with current goals, interventions, progress, and required updates. | RFA Health Equity Plan Requirement and Care Delivery Reporting. | Draft the section from verified plan records, check completeness, and preserve the submitted version. | Yes. | Health equity lead, quality lead, compliance, and authorized submitter. | |
| PO-090 — Ask willing aligned patients for required sociodemographic data | Request the current CMS core data from aligned patients using appropriate language and accessibility support; participation is voluntary, so record a refusal without coercion or fabricated values. | RFA Health Equity Data Collection Requirement. | Present approved questions, capture the patient's responses or refusal, validate allowed values, and support language access. | Yes for the patient's choice and sensitive communication. | Patient or representative; trained assessment or navigation staff. | |
| PO-091 — Ask willing aligned patients for required HRSN data | Collect the current health-related social-needs domains from willing aligned patients, record refusal when applicable, and route identified needs into the care workflow rather than treating them only as reporting fields. | RFA Health Equity Data Collection Requirement. | Present an approved screen, record responses or refusal, summarize needs, and alert the responsible navigator. | Yes for the patient's answers and response to needs. | Patient or representative, trained staff, and care navigator; clinician on safety trigger. | |
| PO-092 — Aggregate and report annual sociodemographic and HRSN data | Create the required participant-level annual reporting from valid patient-level responses, exclude fabricated values for non-disclosure, validate counts, and submit using current CMS instructions. | 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. | Yes for approval and submission. | Quality or data lead, privacy or compliance, and authorized submitter. | |
| PO-093 — Maintain the participant-reported performance-data calendar | Track initial and annual PAAF deadlines continuously and the performance-year final acceptance window, including the current end-of-August date for PROMIS-10 and ZBI-22 data. | PMM §§2.1-2.2 and Exhibit 5. | Calculate patient-level and performance-year deadlines and flag submissions at risk. | No for routine calculation; yes for a disputed period. | Quality lead and data custodian. | |
| PO-094 — Submit complete PROMIS-10 and applicable ZBI-22 performance data | Submit the required patient and caregiver responses and supplemental questions through the current PAAF route within 60 days of initial and annual assessments and no later than the PMM's final performance-year deadline. | PMM §§2.1-2.2 and Exhibit 5. | Validate item-level completeness, assemble the current worksheets or approved submission, and support authorized submission. | Yes for patient or caregiver responses and CMS submission. | Assessment staff, patient, caregiver when applicable, data custodian, and quality lead. | |
| PO-095 — Reconcile performance-data coverage to the aligned population | Compare accepted PROMIS-10 and ZBI-22 records with the BAR and the applicable measure population; distinguish no caregiver, refusal, missing assessment, rejected PAAF, and late data instead of collapsing them into one missing bucket. | Necessary performance work under PMM §§2.1-2.4. | Calculate coverage, produce a patient-level exception list, and trace each gap to its source. | Yes for corrections and interpretation. | Quality lead and data custodian; clinical owner for care-related gaps. | |
| PO-096 — Follow the current PY 2026 high-risk-medication reporting rule | Do not build or submit an obsolete HRRx workbook: the PMM says PY 2025 HRRx reporting is not required and, beginning PY 2026, CMS calculates DAE from claims with no additional participant data report. | PMM §2.3. | Compare the reporting calendar with the current PMM and remove obsolete participant-reporting work. | Yes to approve the current reporting plan. | Quality lead, pharmacy or clinical lead, and data custodian. | |
| PO-097 — Review quarterly DFT results and the annual PBA workbook | Retrieve available CMS performance results, compare them with benchmarks and internal data, investigate unexpected movement, and turn findings into approved quality-improvement work. CMS describes this access but does not make quarterly review a public minimum. | PMM §§2.4-2.5. | Import the workbook, trend measures, identify denominator or performance anomalies, and draft a review packet. | Yes for interpretation and action selection. | Quality lead, finance, program director, and clinical leaders. | |
| PO-098 — Correct remediable performance-data problems before the deadline | Investigate rejected, incomplete, duplicate, or mismatched PAAF records; correct only with source evidence and resubmit through the permitted process before the applicable final date. | Necessary delivery work supporting PMM §2.2. | Identify the exact failed record and field, assemble its source, route approval, and track accepted correction. | Yes. | Data custodian, quality lead, and clinical or enrollment owner according to the field. | |
| PO-099 — Maintain the GUIDE audit file | Keep copies of documentation related to use of model payments and implementation of GUIDE for the retention period and detail required by the executed Participation Agreement. | 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. | Yes for retention policy and evidentiary judgment. | Compliance records owner, finance, quality, and GUIDE program director. | |
| PO-100 — Respond to CMS monitoring and audit requests | Identify the request, preserve relevant records, assemble complete and accurate evidence, have accountable owners review it, and submit by the stated deadline without altering source records. | RFA Participant Monitoring and Auditing. | Create the request inventory, collect linked evidence, detect omissions, and track owner approvals and due dates. | Yes. | Compliance, legal, quality, finance, clinical owner as applicable, and authorized submitter. | |
| PO-101 — Cooperate with the independent GUIDE evaluation | Complete required surveys and participate in interviews, site visits, and other CMS-determined evaluation activities; support authorized evaluator contact while protecting privacy and operational continuity. | Current FAQ Q17; RFA Evaluation. | Track requests, schedule participants, assemble approved factual materials, and record completion. | Yes. | GUIDE program director, evaluation liaison, privacy or compliance, staff participants, and clinical owners when relevant. | |
| PO-102 — Keep the Beneficiary Alignment Report reconciled | Regularly compare the BAR with the participant's active GUIDE population, tier, residence, and effective dates; investigate a patient who appears internally active but not currently aligned or vice versa. | PMP §2.13 and Appendix H. | Import the current BAR, match records, and produce an exception list. | No for routine matching; yes for exceptions. | Data custodian, program operations, and billing. | |
| PO-103 — Monitor Medicare coverage and payer changes | Identify loss of Part A or B, enrollment in Medicare Advantage, an SNP or PACE, or loss of Medicare-primary status; compare effective dates with CMS's BAR update. | PMP §2.13.1. | Compare authorized eligibility data over time and flag an effective or pending disqualifying change. | Yes for exception resolution and transition. | Enrollment or billing eligibility staff and program operations. | |
| PO-104 — Monitor hospice election, death, nursing-home residence, and prolonged inactivity | Identify a hospice election, death, long-term nursing-home residence, or eight consecutive months without either a DCMP or GUIDE Respite Services claim; verify dates and do not wait for an annual assessment to surface a claims-based unalignment condition. | PMP §2.13.1. | Compare authorized claims, eligibility, residence, and internal activity records and flag a potential CMS unalignment. | Yes for verification and family communication; clinical review on hospice or care transition. | Program operations, care navigator, billing, and clinical team on trigger. | |
| PO-105 — Monitor residence and service-area changes | Ask about moves, record awareness date and new setting, determine whether the patient remains inside the service area and an eligible residence, and start the RCC or Memory Care Unit transition rule when applicable. | 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. | Yes for ambiguous setting and transition decisions. | Care navigator, program operations, compliance, and data custodian. | |
| PO-106 — Act on evidence that the patient no longer has dementia | A change in diagnosis must be confirmed by written attestation from a clinician on the Practitioner Roster before the participant submits the resulting mandatory unalignment. | PMP §2.13.2. | Collect the clinical evidence and prepare the unalignment data, but never decide or sign the diagnostic attestation. | Yes. | Dementia-proficient roster clinician and data custodian. | |
| PO-107 — Receive and document a request to stop GUIDE services | When the patient or caregiver asks to stop, document the request and awareness date in the medical record, acknowledge the choice without pressure, and begin the CMS unalignment deadline. | PMP §§2.13.2 and 2.14; Appendix G. | Capture the request, calculate the 15-business-day deadline, and prepare an acknowledgment. | Yes. | Patient or caregiver makes the choice; care navigator or program operations documents it. | |
| PO-108 — Submit stop-request unalignment within 15 business days | Notify CMS through the unalignment PAAF within 15 business days after becoming aware that the patient or caregiver wants to stop GUIDE services. | PMP §2.14 and §2.13.2. | Prepare the PAAF from the documented request, calculate business days, and support the authorized submission. | Yes for submission. | Approved data custodian and program operations. | |
| PO-109 — Submit mandatory participant-reported ineligibility unalignment | Submit an unalignment PAAF when the patient moves to an ineligible residence, moves outside the participant service area, or no longer has dementia as confirmed by the required written clinician attestation. | PMP §2.13.2. | Assemble the verified reason, dates, and supporting evidence and prepare the authorized PAAF. | Yes. | Data custodian, program operations, compliance, and clinician for dementia status. | |
| PO-110 — Optionally report death, hospice election, or planned permanent nursing-home move | When the participant learns of one of these events before CMS claims-based processing, it may submit an unalignment PAAF with verified dates so the BAR can be updated. | PMP §2.13.2. | Gather the verified event evidence, prepare the optional PAAF, and track the CMS result. | Yes for the choice and submission. | Program operations, data custodian, billing, and clinical team as applicable. | |
| PO-111 — Confirm the CMS unalignment result and effective date | Retrieve the updated BAR, identify the actual alignment end date, and apply the standard or special effective-date rule for hospice, Medicare Advantage, PACE, or death rather than assuming month-end in every case. | PMP §§2.13.2-2.13.3. | Match the CMS result, calculate the operational stop date, and flag a conflict with the reported event. | Yes for discrepancies and billing release. | Data custodian, program operations, and billing. | |
| PO-112 — Send the required unalignment notice within 30 days | Within 30 days after receiving notice or confirmation in the BAR, provide the patient written notice using the CMS Appendix F template. Do not send that letter when the patient is deceased or has elected hospice, as the template footnote directs. | PMP §2.13.4 and Appendix F. | Populate the current template, calculate the deadline, apply the stated exception, and track delivery. | Yes for release and sensitive communication. | Program operations or care navigator; compliance on exception. | |
| PO-113 — Retain proof of the unalignment notice or documented exception | Keep the BAR confirmation date, applicable template, delivery evidence, failed-delivery follow-up, or the evidence supporting the deceased or hospice exception. | Necessary evidence for PMP §2.13.4 and Appendix F. | Archive the record and alert before the 30-day deadline expires. | No for routine capture; yes for failed delivery or exception. | Program operations and compliance records owner. | |
| PO-114 — Cease GUIDE billing at the applicable unalignment date | Stop GUIDE-specific billing according to the CMS effective date, account for special timing for Medicare Advantage, PACE, death, and hospice, and prevent claims with disallowed dates of service. | PMP §2.13.3. | Apply the BAR effective date to billing eligibility and flag claims that cross it. | Yes for billing correction and exception handling. | Billing, finance, data custodian, and compliance. | |
| PO-115 — Limit transition-period service and billing to the permitted window | For an RCC or Memory Care Unit move, use only the applicable 60-day or 15-day transition period and complete required transition and unalignment actions before it expires. | PMP §2.12. | Display the permitted window, track required actions, and flag service or billing after its end. | Yes. | Program operations, care navigator, billing, and compliance. | |
| PO-115A — Submit final GUIDE claims after Memory Care Unit unalignment within 30 days | When a patient unaligns after moving to a Memory Care Unit, submit every otherwise valid final GUIDE payment claim within 30 days after the effective unalignment date; do not use this special deadline as authorization for services after unalignment. | 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. | Yes for claim review and submission. | Billing, finance, program operations, and compliance. | |
| PO-116 — Coordinate continuity when GUIDE alignment ends | Explain what is ending, identify active clinical and community commitments, hand off time-sensitive needs, and help the patient or caregiver connect with ongoing care without implying that ordinary Medicare care ends. | Necessary delivery work supporting PMP §§2.12-2.14. | Assemble the active-care summary, open commitments, contacts, and patient-facing transition checklist. | Yes. | Care navigator, clinical team for clinical handoff, and program operations. | |
| PO-117 — Cooperate when the patient changes GUIDE participants | Acknowledge the new participant's care-coordination outreach, provide requested authorized documentation, and make a good-faith transition while the new participant completes its own consent and alignment process. | PMP §2.14. | Prepare the authorized transfer packet, track the request and disclosure, and identify unresolved care handoffs. | Yes. | Care navigator, health-information staff, privacy owner, and clinical team as needed. | |
| PO-118 — Close the internal GUIDE episode only after required work is complete | Record the CMS effective date, stop billing, complete the required notice or exception, finish transition actions, preserve the audit record, and distinguish closed GUIDE alignment from continuing non-GUIDE care. | 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. | Yes for final closure approval. | Program operations, billing, care navigator, compliance, and clinical owner when needed. | |
| PO-119 — Build and maintain the potential-patient referral network | Establish working referral routes with primary care, neurology, hospital and discharge staff, community organizations, and other relevant groups; agree on referral criteria and protocols for diagnosed and suspected dementia, keep mild cognitive impairment distinct, and comply with applicable fraud-and-abuse law. | PMP §2.2. | Maintain the referrer directory, approved criteria, referral instructions, and source-by-source volume and follow-up list. | Yes. | GUIDE outreach or network lead, program director, compliance, and clinical advisor. | |
| PO-120 — Conduct potential-patient outreach without coercion | Contact potentially eligible people through approved routes, explain why they were contacted, offer an intake conversation, honor refusal, and avoid pressure, steering, or claims that the person is already eligible or aligned. | 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. | Yes. | Trained outreach or enrollment staff; patient or caregiver decides whether to proceed. | |
| PO-121 — Document a temporary residence period | When an aligned patient temporarily lives elsewhere, record the temporary location and duration in the medical record; do not add that temporary location to the service area solely for the temporary move, and bill a DCMP during the period only when GUIDE care-delivery services are actually furnished through an allowed route. | 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. | Yes for confirming the facts and care plan. | Care navigator, program operations, and billing. | |
| PO-122 — Confirm monthly DCMP claim readiness | Before billing a month, confirm final BAR alignment and tier, an allowed date of service, every applicable tier touchpoint, and at least one actually furnished non-respite GUIDE care-delivery service. A compliant required touchpoint may be that one service; an off-contact low-dyad or RCC month may use a documented non-contact service while cadence remains current. The service record must identify the legitimate patient-specific purpose or need, actual action, authorized actor/organization, participant interaction or sources used, the specific person-facing result for a contact-based service, and the truthful outcome, including no-change only when a real interaction or review produced that result. Unasked domains cannot be converted to no-change outcomes. Maintaining infrastructure, passive monitoring, AI analysis, reminders, failed outreach, administrative pursuit alone, cosmetic documentation, duration, or a generic check-in does not support a DCMP claim, and an overdue touchpoint blocks billing until completed. | 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. | Yes for billing release and exceptions. | Billing owner, program operations, navigator-contact owner, and service-documentation owner. | |
| PO-123 — Prepare the monthly DCMP claim correctly | Use the aligned patient's MBI, a valid dementia diagnosis code, the tier-specific DCMP G-code, and the earliest date in the calendar month on which a GUIDE care-delivery service occurred; use the alignment or initial-assessment date as directed for the first month and submit the GUIDE-specific G-code on the required standalone claim. | 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. | Yes for claim submission. | Certified billing staff or billing vendor with participant oversight. | |
| PO-124 — Prevent a duplicate DCMP claim in the same month | Ensure only one DCMP HCPCS code is billed for the same patient and calendar month, including when the tier changes or more than one team member furnished services. | 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 routine check; yes to correct a duplicate. | Billing staff and revenue-cycle compliance. | |
| PO-125 — Prevent separate billing for PFS services included in the DCMP | For an aligned patient, do not separately bill the Medicare PFS services CMS lists as included under the DCMP; account for overlapping-model participation without ignoring GUIDE's duplicate-payment rules. | 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. | Yes for billing disposition and exceptions. | Billing compliance, revenue cycle, and clinical coding owner. | |
| PO-126 — Reconcile DCMP claims, denials, recoupments, and payment reports | Match submitted patient-month claims to remittance and CMS payment information, investigate denials or recoupments, correct supported claim errors, 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. | Revenue cycle, finance, billing compliance, and program operations. | |
| PO-127 — Keep CMS-calculated measures out of the participant-reporting queue | Treat DAE, TPCC, and LTNH as CMS-calculated claims or administrative-data measures; do not invent participant submission files for them, while still reviewing CMS results for quality improvement. | PMM §§2.1-2.3. | Maintain the measure-source map, suppress obsolete reporting tasks, and route available results to the performance review. | Yes to approve the reporting calendar. | Quality lead, data custodian, finance, and clinical leaders. | |
| PO-128 — Maintain QPP MIPS reporting separately from GUIDE reporting | Determine whether the participant and clinicians are QPP MIPS eligible and, when they are, complete MIPS reporting through QPP in addition to GUIDE-specific reporting; GUIDE is not an Advanced APM and GUIDE submissions do not satisfy MIPS. | PMM §1.5. | Maintain separate obligation calendars and measure inventories and flag an attempt to treat one submission as the other. | Yes. | Quality reporting lead, eligible clinicians, compliance, and QPP or MIPS reporting owner. | |
| PO-129 — Maintain the CMS data request and attestation for participant data feeds | State which CMS claims or other participant data are requested for GUIDE health-care operations, attest that the request is minimum necessary, record the participant's data-sharing selections, and keep authorized recipients and uses current. | 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 attestation and data-use decision. | Privacy officer, compliance, data lead, security owner, and authorized signatory. | |
| PO-129A — Explain and honor the beneficiary's claims-data-sharing preference | Give the patient or caregiver the current required information about beneficiary-identifiable claims-data sharing for care coordination and quality improvement, explain how to change the preference or opt out, record the choice without affecting care, and apply the current CMS process. | 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. | Yes for the patient choice and communication. | Patient or authorized representative; enrollment or care-team staff; privacy and data operations implement the preference. | |
| PO-130 — Verify provider preference after a new pending-alignment notice | When CMS signals a new pending alignment to another participant, acknowledge the new participant's outreach and directly confirm the patient or caregiver's provider preference within 15 days without attempting to influence the decision. | PMP §2.14. | Start the deadline, prepare neutral questions, document the direct conversation, and flag an unresolved preference. | Yes. | Patient or caregiver; current care navigator or program operations conducts the neutral conversation. | |
| PO-131 — Send care-transition information to the new participant within 15 days | After authorized outreach from the new participant, assemble and provide the care-transition information within 15 days and document the disclosure and any unresolved time-sensitive need. | PMP §2.14. | Assemble the authorized transition packet, calculate the deadline, check for missing current information, and track receipt. | Yes. | Care navigator, health-information staff, privacy owner, and clinical team for clinical content. | |
| PO-132 — Complete the receiving-participant side of a GUIDE transfer | Ask whether the patient currently receives GUIDE services elsewhere, confirm that the current participant was notified, request documentation of that notification, coordinate the handoff, and then complete the full voluntary-consent and alignment process rather than assuming the transfer is automatic. | 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. | Receiving participant's enrollment staff, care navigator, data custodian, patient or caregiver, and clinical team as needed. |
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 | Clinical review on trigger |
| 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 | Clinical review on trigger |
| 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 | Clinical review on trigger |
| PO-029 — Assemble the complete initial PAAF packet | Public 2026 requirement | Compliance infrastructure | Clinical review on trigger |
| PO-030 — Check the PAAF for completeness, dates, and internal consistency | Necessary delivery work | Compliance infrastructure | Clinical review on trigger |
| 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 | Clinical review on trigger |
| 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 | Clinical review on trigger |
| 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 | Clinical review on trigger |
| 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 | Clinical review on trigger |
| 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 RFA care-delivery 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 RFA care-delivery requirement | Compliance infrastructure | No clinical judgment |
| PO-057 — Document the clinician's dementia-proficiency basis | Public RFA care-delivery 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 RFA care-delivery 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 transition for a move to an unapproved or uncontracted RCC | 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 | Clinical review on trigger |
| 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 | Clinical review on trigger |
| 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 | Clinical review on trigger |
| 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 | Clinical review on trigger |
| 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 | Clinical review on trigger |
| 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.