Rule catalog

Status: Contract, Care Plan, Care Coordination, and Medication Management semantic rule map, v0.2

This is the target business-rule contract, subordinate to the source hierarchy in README.md, SETTLED decisions in 08_Decision_Log.md, the roles contract, and the applicable pillar SOP. machine/sop-0.2.schema.json and the Care Plan YAML do not yet implement every field below (notably edge-case linkage, rule-specific category assertions, and full clock/task/evidence execution). Until that migration is complete, the machine artifacts remain non-activatable.

Rule contract#

Every production rule contains or references the following machine-enforceable contract. Free-text purpose and action descriptions never substitute for typed guards, transitions, clocks, tasks, or evidence.

rule_id: CP-001
version: 2.0.0
status: draft | validated | active | retired
pillar: care_plan
material: true | false
purpose: plain-language description
edge_case_ids: [stable edge-case IDs]
automation_class: none | evidence_only | administrative | clinical_execution | external_release
input_requirements:
  - fact_id: stable fact ID
    accepted_record_states: [explicit epistemic states]
    current_required: true | false
    value_contract_id: typed value contract
condition:
  fact: stable fact ID
  target: record_state | value
  path: JSON Pointer declared by the value contract
  op: typed operator
  value: typed operand, omitted only for exists/not_exists
unknown_policy: explicit fail-safe or RULE_GAP_HOLD; never implicit permission
outcome:
  transition_id: stable transition ID
  transition_class: advance | hold | evidence_pursuit | safety_escalation | terminal | retry | task_outcome | rule_gap
  from_state: exact source
  to_state: exact destination
  permitted_automation: [bounded actions]
task:
  task_type: null or approved task type
  owner_role: exact role
  backup_role: exact role
  edge_case_ids: []
  payload_contract_id: typed task payload
  idempotency_key_fields: [declared paths]
  allowed_outcomes: [typed outcomes and transitions]
clock:
  origin: state/task/event timestamp
  duration: ISO-8601 duration or NONE
  calendar_id: versioned calendar
  timezone: IANA timezone
  on_miss_transition_id: explicit transition or null
retry:
  strategy: none | fixed | exponential
  max_attempts: bounded integer
  interval: ISO-8601 duration or NONE
  retry_transition_id: explicit transition or null
  exhaustion_transition_id: explicit transition or null
authority:
  required_actor: role or NONE
  decision_scope: exact affected element/version
priority: P0 | P1 | P2 | P3
blocked_actions: []
evidence_ids: []
audit_artifacts: []
billability_effect: none | supporting | qualifying | blocking
source_basis: []
test_case_ids: []
owner: named function
approval: [clinical, compliance, privacy, operations, product as applicable]
effective_at: timestamp or null
retired_at: timestamp or null

Condition evaluation uses TRUE, FALSE, and UNKNOWN. Only TRUE enables an ordinary action transition. Missing, stale, conflicted, retracted, superseded, future-received, or otherwise ineligible values cannot satisfy a negative comparison. Zero safe matches, unsafe unknowns, or overlaps enter an explicit rule-gap hold. Tests link bidirectionally to rules and must prove rule-specific positive, negative, ambiguous, and failure behavior rather than merely carry a category label.

Automation-class invariants:

• clinical_execution requires a structured, current, scope-matched licensed-authority event naming the actual actor, credentials, organization, affected element/version, and allowed action. required_actor: NONE is invalid.
• external_release remains unavailable to L0 outside an actually approved automatic class. D-033 selects only routine authorized-provider requests/information and unchanged clinician-approved recommendations to selected PCP/specialist for approved-rule sending without an extra per-packet OK. Every exact recipient, purpose, content, channel, lawful basis/restriction and genuinely required review must still be valid. D-007's ordinary community referral and person-specific oral introduction retain the assigned Puerto Rico navigator's human release and designated navigator-lead backup; every correction/resend in that class requires its new exact event. Protected clinical acts occur first within actual US authority, and the navigator does not approve medical substance. Care Plans, patient orders/counseling and special/uncovered classes retain their own conditions; unresolved required authority holds only its affected act. This is the semantic D-033 exception, not a deployed care-engine permission.
• Evidence preparation, routing, or task creation never inherits the authority of the person expected to resolve the task.
• Any OPEN/BLOCKED decision referenced by the rule prevents production activation and any closure path dependent on that decision.
• A community-service first-use usefulness result may not be marked not_applicable until O-062 approves the service class, event-based timing, evidence, and exact not-applicable condition. Operator preference, workload, silence, or an organization report cannot select that result.

Care Plan stable-ID migration map#

The current machine file contains CP-001 through CP-023 with gaps at CP-008, CP-015, and CP-016. Those gaps must not be reused because this folder has no Git history from which retirement can be disproved. Existing IDs are preserved; semantic rewrites increment their major version and remain draft.

Draft version targets are 2.0.0 for CP-001-005, CP-007, CP-009-010, CP-012-014, CP-017-018, and CP-020-023; CP-006, CP-011, and CP-019 target 3.0.0. Every material rule uses exact rule-specific tests CP-T-<RULE-ID>-POS, -NEG, -AMB, and -FAIL, plus edge/boundary cases. source_basis must name the exact source IDs/sections or decision IDs in this catalog; a generic "CMS" citation is invalid.

Legacy Care Plan test-ID migration#

The existing IDs are preserved and rewritten as executable v0.2 fixtures; they are not silently retired or replaced. New rule-specific and edge-specific IDs supplement them.

Care Plan semantically versioned rules#

CP-006 — Confirm or clarify an unconfirmed choice#

An AI interpretation, copied prior preference or unconfirmed conversational inference remains a candidate. Present the exact proposed choice, option/plan element and material conditions to the beneficiary or decision-specific authorized representative through the approved accessible route. That person may confirm, correct, decline, defer, ask a question or request an alternative directly. Software records the attributable response and applies the approved identity, authority and evidence checks; AI does not confirm its own extraction.

Use L2 only for a required human planning act, requested help, unresolved meaning, disagreement, distress, accessibility failure, relationship work or another actual D-021 trigger. A clear authenticated response whose route/evidence requirements are satisfied does not create NAVIGATOR_VERIFY merely because it arrived digitally. A participating caregiver may confirm that caregiver's own input, not substitute a beneficiary choice without decision-specific authority.

Unknown identity/authority, no response, conflicting choice, failed understanding or unmet route prerequisites keep only the affected choice unresolved. Clinical meaning, medication/treatment changes and clinical-capacity questions go to the exact authorized professional; a complete uncovered legal-authority question goes to Healthcare Legal Counsel. Confirmation records the person's decision, not clinical appropriateness, disclosure permission, required human contact, whole-plan completion or service execution. O-041 still controls which modes and evidence are accepted; no AI-only end-to-end planning approval is inferred.

Checks: a clear approved digital confirmation with no L2 task; correction of an AI-misstated option; an expired representative document; caregiver dissent without a controlling veto; requested navigator help; inaccessible explanation; conditional acceptance with cost still unknown; a requested medication change; silence; and required human-service work that remains separate. Legacy machine representations remain non-activatable and are not migrated in this semantic pass.

CP-011 v3.0.0 -- Decision-specific authority conflict#

IF an affected plan element has authenticated competing choices
AND controlling decision-specific authority is UNKNOWN, CONFLICTED,
    EXPIRED, CONDITIONAL_UNRESOLVED, or CAPACITY_REVIEW_REQUIRED
THEN state = AUTHORITY_UNCLEAR
AND affected_element = BLOCKED
AND all assertions/dissent remain immutable
AND create the authority/capacity task permitted by O-011

If a capable authenticated beneficiary controls the decision and caregiver authority is noncontrolling, CP-011 is FALSE; caregiver dissent is retained but does not block CP-009.

CP-019 v3.0.0 -- Version-bound care-plan distribution failure#

IF RECIPIENT_OBLIGATION_MANIFEST identifies a required current obligation
AND DISTRIBUTION_LEDGER records a release/transmission/delivery/access failure
AND the versioned channel policy requires correction, retry, or exhaustion handling
THEN state = DELIVERY_FAILED
AND the committed plan version remains active
AND create only the task allowed by recipient authority, D-007, O-012, and O-014

Release, transmission, delivery, access, receipt, refusal, failure, exhaustion, and authorized exception are distinct values. An automated retry may not create a new PHI release. Failure or retry exhaustion is never satisfaction and cannot enable CP-018; it remains open in DELIVERY_FAILED unless a pre-existing exception class is later permitted by settled O-012.

Proposed new Care Plan rule reservations#

The following are design reservations, not yet authoritative assignments. Confirm them against any external rule history before writing the v0.2 Care Plan YAML. CP-008, CP-015, and CP-016 remain unused/reserved. Each reservation targets draft version 1.0.0, must cite the source/decision shown, and must use stable rule-specific test IDs before integration.

24/7 access business-authority interpretation#

D-026 and X-019 distinguish continuous first-answer access from an actual care-team or protected clinical act. Human-answer readiness checks the approved Philippine L1 nurse rota, actual answerability, relief/concurrency and shift-lead recovery. It does not demand a continuously staffed Puerto Rico or in-house clinician lane solely from public RFA §3.1.

A receiving act checks its own approved performer, membership or professional authority, current location where needed, actual route hours, response/acceptance, backup and unavailable-route treatment. Direct substantive caregiver support remains a care-team act under §§3.2/8.3.4; Philippine membership/support scope stays O-001. Individualized clinical waiting/urgency decisions remain with the approved clinical response policy or actual authorized professional. A first-answer event does not complete those receiving acts, formal navigator contact, required record sharing or later callback work. Unresolved O-008/O-001/O-PA-001 still prevents off-duty-record release, not source-faithful preparation or independent emergency-safe help.

Semantic checks: routine 2 a.m. factual answer with zero L2/L3/L4 time; caregiver request with unapproved versus approved care-team scope; protected question when a usual professional is off duty; accepted but unperformed callback; failed receiving route with immediate emergency cue; source-verified but unreleased off-duty record. No new machine rule IDs, timers or implementation are introduced in this semantic correction.

Care Coordination semantic rule map#

Status: DRAFT v0.2 semantic meanings only. New numeric rule IDs are deliberately not assigned until the Care Coordination semantic contract, the full semantic SOP set, and the later fault gates are complete. Existing stable IDs CC-021, CC-033, and CC-047 are retained and require major semantic version changes rather than silent prose edits.

Care Coordination rules must preserve these business invariants:

• one parent case contains applicability-aware, route-specific obligations; there is no universal referral chain;
• receipt, access, appointment, encounter, document, service, and care-plan outcomes belong to their exact recipient/attempt/episode/version;
• missing proof is UNKNOWN or missing evidence, not Boolean false;
• an attempt, task escalation, local edge resolution, or child-obligation outcome does not automatically close the parent case;
• successful specialist-loop closure, truthful non-success case disposition, and GUIDE service qualification are different results;
• urgency is a cross-case interrupt, not a routing class;
• terminal cases are immutable; late material evidence may open a linked successor; and
• every OPEN/BLOCKED decision referenced by an obligation prevents activation of the dependent path.

Route-specific obligation families#

An attributable professional product, the coordination-parent outcome and each downstream child service result are separate. A missing prerequisite needed for today's clinical decision prevents a successful product; a future pending test or monitoring task with an accepted reviewer, timing, return and safeguards does not erase one already completed. A current scope-matched referral basis or substantive PCP consultation may be reused without another judgment act. Specialist loop closure follows its actual documentation/plan/notice/introduction/consultation manifest; it does not wait for unrelated future child service execution. Starting Medication work never supplies the required §5.4 reconciliation product. D-026's nonclinical human line does not create continuous clinical or Puerto Rico staffing; O-054 controls the actual licensed response promise. These are draft business meanings, not new numeric rules or runtime activation.

CC-021 v2 target -- Required receipt or access evidence remains unknown#

CC-021 applies only when a route-specific policy requires receipt or access evidence for the exact release/request. Its trigger is a canonical release event, a due clock under settled policy, and the absence of a correctly matched receipt/access event as of evaluation. It must preserve explicit rejection, delivery failure, late evidence, wrong recipient/version, and unknown as distinct facts.

Its permitted outcome is a bounded administrative pursuit task and waiting/exhaustion disposition for that obligation. It cannot convert unknown to false, authorize a re-send, satisfy the obligation, or close the parent case. Timer origin, calendar, attempts, backup, channel sequence, and exhaustion remain blocked by O-004/O-020/O-021.

Minimum tests: required versus not-required receipt; no matched event; explicit failure; wrong-version receipt; late receipt; duplicate receipt; retry exhaustion; and parent case with another open obligation.

CC-033 v2 target -- Encounter occurred but matched documentation is absent#

CC-033 applies only to a specialist/provider path for which a canonical encounter-completion event exists and the required correctly matched visit documentation is absent as of the settled clock. A candidate, partial, illegible, wrong-patient, wrong-encounter, or unverified document does not satisfy the obligation.

Its permitted outcome is records pursuit and continued specialist-loop hold under D-009. Receipt of valid documentation resolves only the document obligation; successful loop closure still requires authorized reconciliation and resulting child work. Explicit no-record response and exhaustion remain non-success facts, not closure evidence.

Minimum tests: no encounter; encounter/no note; wrong note; partial note; valid note/no reconciliation; valid note/no-change disposition; late note after nonterminal case; and late material note after terminal case.

CC-047 v2 target -- Possible clinical instruction reaches administrative support#

A raw or candidate signal that may contain a new clinical instruction is sufficient to impose the conservative administrative block. It is not sufficient to verify the instruction or authorize action. L1 records the content verbatim, does not interpret or relay it, and invokes routing to the actual role required by O-003; an RN is not a universal destination.

Only an authenticated, scope-matched clinical disposition may clear the block and determine the resulting care-plan, medication, coordination, or communication action. Wrong-patient content also invokes identity/privacy review.

Minimum tests: purely administrative response; mixed content; false positive; unverified sender; wrong patient; medication order; urgent symptom; authorized no-action disposition; and attempted L1 relay.

Medication Management semantic rule map#

Status: DRAFT v0.2 semantic meanings only. New numeric rule IDs are deliberately not assigned until the Medication semantic contract, the full semantic SOP set, and the later fault gates are complete. Existing stable IDs MED-017, MED-023, and MED-041 are retained and require major semantic version changes rather than silent prose edits.

Medication rules must preserve these business invariants:

• request/proposal, order, transmission, pharmacy response, dispense/reversal, possession, reported use, administration, reconciliation, stop/cancel/disposal, provider agreement, instruction, and execution remain separate event families;
• CONFLICTED links retained assertions and never overwrites them;
• a shared reconciled regimen is a time-bound prescribing-clinician disposition over a named evidence snapshot, not proof of actual use and not a replacement for source provenance;
• every applicable initial/future assessment reaches a clinician with actual prescribing authority, including clean/no-change cases;
• terminology normalization and clinical-review-condition detection do not decide equivalence, risk, urgency, advisability, treatment, or causality;
• recommendation sharing, the relevant-provider agreement gate, final clinical decision/order, recipient instruction, pharmacy execution, and reported implementation are independent obligations;
• an outside-provider order/recommendation retains its own authority/effective status and reconciliation route; it is neither forced into the GUIDE-originated proposal route nor converted into a beneficiary instruction on receipt;
• missing, stale, reversed, wrong-version, wrong-scope, or otherwise ineligible evidence never becomes negative proof or permission;
• safety can interrupt any case and opens a separate US clinical pathway without asserting medication causality;
• route-specific case closure and GUIDE service qualification are independent; and
• M14/M15's attributable professional review product is distinct from M16 explanation, M29/M30 communication, applicable change/pharmacy execution and each due M31 monitoring obligation. Future follow-up does not erase a completed review; a missing fact required for the current decision supports a truthful incomplete result;
• reuse of a current clinician-authored agreement-provider basis and correction of an objective response defect are not new clinical decisions. Actual clinical applicability, disagreement, prescribing, urgency and interpretation remain protected;
• terminal cases are immutable; late material evidence may open a linked successor.

Route-specific obligation families#

MED-017 v2 target -- Apparent dispense after authorized stop#

MED-017 applies only after the beneficiary/product identity, actual event type, authorized stop decision and effective time, and apparent post-stop dispense/handoff are sufficiently established. A delayed source record, preparation without handoff, partial fill, claim later reversed, wrong patient/product, or dispense that occurred before the stop does not satisfy the same condition.

When the condition is established, preserve the stop, pharmacy, possession, reported-use, and administration planes; create a conflict; withhold any new instruction that assumes either regimen; and route the exact evidence to the prescribing-authority clinician. The rule does not prove pickup, taking, harm, or urgency. P1 cannot be hardcoded while O-004 is open.

Resolving the pharmacy event alone does not close the medication case. The applicable current regimen, possession/use, recipient communication, pharmacy status, and safety obligations must receive their own dispositions.

Minimum tests: valid post-stop handoff; dispense before stop but received late; prepared/not handed over; reversed claim; partial fill; mail order; wrong identity; cancel acknowledgment; household possession; reported taking; no symptoms; and possible safety signal.

MED-023 v2 target -- Unresolved caregiver-reported medication identity#

MED-023 preserves a caregiver report verbatim and keeps the medication identity candidate-only when the source text does not support an exact approved terminology mapping. A probabilistic confidence score may route evidence pursuit; it cannot promote the identity, establish equivalence, or decide whether clinical review is safe to skip.

L0 may request the rule-selected label/source evidence; L1 may request the previously specified bottle image or verified source record; L2 may authenticate the report. Compounds, supplements/natural products, ambiguous strength/form, and illegible labels remain unresolved at the supported level. A possible safety signal from the raw report still invokes the safety path even while identity is unresolved.

Minimum tests: exact deterministic identity; ambiguous brand; wrong strength/form; compound; out-of-scope supplement; illegible image; high-confidence wrong OCR; wrong patient; caregiver correction; evidence never obtained; and concurrent safety signal.

MED-041 v2 target -- No current exact relevant-provider agreement#

MED-041 applies to an exact GUIDE change proposal only after the settled rule establishes two separate manifests: the PCP/applicable-specialist recommendation-sharing recipients and the PCP or medical specialist whose response is required for the agreement gate. It looks for a current, authenticated, scope-matched AGREES event from every provider required by the agreement manifest. It must not require agreement merely because a provider belongs on the sharing manifest, and valid agreement does not erase an unsatisfied sharing obligation. It must not use a generic agreement != AFFIRMATIVE comparison that collapses missing, stale, modified, declined, revoked, wrong-provider, wrong-scope, and wrong-version evidence.

Without the required current agreement, the proposed regimen cannot become active through this route, and dependent medication-change instruction/execution remains blocked. L1 may pursue administrative status; clinician-to-clinician work follows O-005/O-029. MODIFIES creates a new proposal; DECLINES, NO_RESPONSE, UNKNOWN, and REVOKED retain their truthful outcomes. Timeout never grants permission.

Agreement still does not create the final lawful order, recipient instruction, pharmacy execution, reported implementation, or service qualification.

Minimum tests: sharing recipient who is not an agreement authority; agreement authority who overlaps the sharing manifest; exact valid agreement with another share delivery still open; GUIDE prescriber is also the relevant PCP; multiple agreement authorities; office-staff receipt; silence; wrong provider/scope/version; stale agreement; partial/conditional agreement; MODIFIES; DECLINES; revocation; proposal changed after agreement; beneficiary refusal/self-change; and exhausted attempts.

Governance#

Program Operations sourced business boundaries#

These meanings constrain the prose inventory in Manual 18; they are not a new runtime, rule-version scheme or software implementation.

Assessment residence-visit and clinical-subject work rules#

These are semantic work requirements linked to D-028 and AS-E09/AS-E10, not a newly implemented workflow engine.

Ongoing Monitoring and Support work boundaries#

These are semantic procedure requirements, not a new care engine or approved runtime rule.

D-032 selects the accepted primary PR navigator's first family meeting during initial assessment/planning, inside useful existing work. Keep logistical notice, actual human introduction, underlying furnished support/contact, alignment and payment separate. Count actual parent minutes once; do not delay a medical-only/urgent act, duplicate the introduction after final alignment or treat greeting alone as qualified contact. Actual assignment/coverage/mode evidence remains O-053/O-063/O-064.

Caregiver training and support work boundaries#

• Rule changes require version increments and named approval.
• Prior versions and every fact event remain replayable.
• A rule-gap event cannot be handled by allowing an LLM to improvise.
• Emergency and clinical rules require clinical approval before activation.
• Privacy/release rules require privacy/compliance approval.
• Billability rules require compliance and billing approval.
• Changes to executed-PA-dependent assumptions remain blocked until cross-checked against the participant's actual agreement.
• Structural or guard-path validation does not prove clocks, tasks, retries, communications, evidence, closure, regulatory approval, or operational activation.

Access29 semantic reconciliation#

This map refines the existing 24/7 business interpretation without introducing machine rules, new numeric rule IDs, timers or software care implementation.

1. Ready to operate is more than ready to answer. Each on-duty/off-duty interval needs its accepted performer/capacity/scope and actual paid coverage/backup. Public third-party permission is expressly off-duty; D-026's desired all-hour arrangement still needs O-001/O-PA-001 acceptance. Tasks5/21-23 mandatory sharing/release/receipt/acceptance/failure route must operate before the selected third-party helpline launches. A permanent held packet is not compliance. Independent emergency-safe work continues.
2. Prepare the actual protected act. Separate caller, reporter, beneficiary and actual clinical recipient. Subject/current location/act and applicable provider-location authority are checked before each licensed act or callback, independently for both subjects in a mixed call. No nursing title, source keyword or generic RN gateway supplies clinical authority.
3. Count only the result that occurred. Failed pickup/reconnect/transfer is non-success, not completion evidence. Human answer, acceptance, disposition/support, communication, sharing, callback, receiving service and payment remain different. Approved route/response policy or the authorized professional determines clinical waiting; L1/L2 never infer safe morning delay. A factual administrative callback uses L1 when permitted; navigator support or clinical work uses its actual required performer.
4. Preserve mandatory records without invented release authority. Human-only/manual-source documentation survives declined AI. Each actual performer verifies only their own work. Off-duty public sharing, accepted-daytime Proxi all-call continuity and direct care-team records use their correct route. O-008/O-001/O-PA-001 holds unsupported release; an actual approved class-specific paid release and matched receiving acceptance precede any claimed sharing result. No phantom privacy/program worker or free Participant releaser.
5. Reuse, do not bless or bypass. Only authoritative current scoped applicability permits faithful reuse with0 new clinician minutes. New symptom/conflict/subject/location/use/question, expired/conditional guidance or due required professional review opens the exact act. AI/L1/L2 never decide clinical equivalence or sufficiency.
6. Availability and service labor are different denominators. Task1's paid PH pool carries availability and embedded L1/lead work once; actual L2/clinical/contracted service and selected availability/portfolio setup are separately paid. CG26 and other receiving-service events are not rebilled as Access labor. An outside endpoint's own act differs from a Proxi-paid GUIDE contractor. Qualification and payment remain separate from care completion; infrastructure alone is not a furnished monthly service.

Detecting cases: AC-E01..06 and all29 literal source links, with current/unknown/conflicting/duplicated/late facts, clinical subject/location changes, unavailable receiver/attestor, human-only recording, shared events and truthful non-success. Clinical/Participant/field approval remains open.

Referral57 semantic reconciliation#

This is the meaning of the reviewed work, not a new care engine, machine schema, timer or numeric rule catalogue.

• Exact offering: one service seeker/recipient/current need, named organization/programme/offering, geography and as-of time. Corroborated identity may match a current record; otherwise retain observed candidate/conflict without force-merging or dropping. Current source, hard requirement, preference, operating/inquiry/application/opening, criteria/cost/waitlist and unknowns remain different facts.
• Actual navigator versus preparation: software/AI may prepare current facts/options and capture a clear person choice with0 new L2. Section6.3 names navigator referral/connection for assessed HRSN resources. Actual ordinary referral initiation and D-007 assigned-L2/approved-lead release are paid and may share the existing1/1/2 event; service content and a release click are different evidence. Resource-only/self-referral is not that same act or automatic qualification.
• Purpose determines class: owner/data class, recipient/purpose/content/channel, applicable approved basis or required authorization, restrictions/revocation, actual class-specific release, execution and matched receipt. No-PHI general information has no PHI release; ordinary nonclinical referral uses D-007; other HCBS coordination/service-list/clinical/special-data content retains its own O-008/O-021/actual matrix. Corrected/re-sent/changed-destination disclosures require their actual new release event; no blanket D-007 or blanket blocked person-specific work.
• Four returns: local actual referral milestone/closure, actual furnished Proxi GUIDE act/content/result, later usefulness under O-062, and monthly qualification/payment O-009/O-025/O-047 remain separate. Actual first furnished/used service is Proxi's O-022 start design, not CMS's only connection definition. A real Proxi service may coexist with outside denial/waitlist; inventory, preparation, L1 pursuit, a release click or outside start alone does not establish a new furnished/payment service.
• Programme and organization authority: §6.1 supports direct, written local AAA/TitleVI assistance or both. Actual official counterpart, terms/paid assistance, entity/signature, Partner acceptance where required, tested operation and assistance return are evidenced. D-027 company business approval differs from O-066 actual company signer and any truly retained Participant act O-PA-001. Current unchanged accepted terms need no new approval; signed paper alone is not actual assistance or a functioning route.
• HCBS predicate and review: §6.2 applies only if eligible AND currently receiving state Medicaid HCBS. Preserve actual programme/manager/source/effective authority and genuine contact/attempt versus response/acceptance. It does not guarantee cooperation or live L2. Standard information, source ingestion, clear summaries/approved nonclinical deltas and factual action tracking can be digital; actual substantive/relationship work has the original conditional/shared minutes. G52/53 under O-023 preserves actual asynchronous/substantive joint-review/finding acceptance; candidate comparison is not programme eligibility, clinical equivalence, payment duplication or a stopped service.
• Actual clinical subject: every protected question uses actual clinical recipient/current location/act plus applicable provider-location authority, separately from reporter/caller and independently for dual subjects. No PR clinical or default RN/L2 gateway. Current authoritative scoped answers are reused without blessing; new symptom/conflict/location/question or due professional review re-enters that exact act. Independent emergency-safe work is not delayed for a packet.
• Time and jobs once: one manual search/intake batch13minutes, one HCBS administrative0/5/13 episode, one actual shared human interaction and exact actual releases—not one charge per candidate/row/status. Selected portfolio priority decisions27/35 are paid Proxi design, not CMS-mandated human reviews. Direct current organization source/electronic recheck can be0 staff; actual manual work keeps its stated event/batch range. Outside own programme acts differ from contracted GUIDE assistance/interpretation/provider fees, which are Proxi cost. Real L1/L2 lead, technical, business, Medicaid, Billing, Legal or actual professional work replaces generic owners.

Detecting cases RF-E01..08 below the shared edge register, all57 exact source links and the independent reader cases cover unknown/stale/conflicting/duplicated/late facts, no-match, mixed owners/classes, release correction, true first use, outside nonresponse, signatures, data versus joint review, exact authority and shared labour. None is field/CMS/clinical approval.

Enhanced106 semantic reconciliation#

This describes the business acts, not a new engine, machine schema, state/version or timer.

• Required floor versus extra: each106 label has a named baseline interface and either a distinct candidate additional result or an explicit no-extra baseline-only result. No optional selection gates required GUIDE work, SV07 accessibility or AC02 actual human access. One episode/content/time is counted once; an extra label is not an extra contact/service or payment record.
• Defined digital versus protected result: BD05 collects nonclinical practical facts, LC04 matches an approved taxonomy to a direct choice, AC01 records attributed usual observations/general education, and AC09 compares reports. None determines cause, safety, clinical stability, individualized warnings or clinical baseline. Protected results are separately authored. Selected WN09 is an actual D-019 L2 safe rehearsal/application; digital preparation is not its completion.
• Real paid act: D-012 supplies in-scope paid work. O-052 chooses and funds actual additional Proxi-furnished professional care versus honest coordination-only; no free Participant clinician/navigator/releaser or unaccepted contractor. One actual professional is selected for the exact act, subject/location/provider authority and modality; no universal RN/L2/CMO queue.
• Preparation without substitution: source/identity/as-of/unknowns and the exact question precede human judgment. Current products can be reused only when authoritatively applicable; new symptoms/conflicts/location/question or due work re-enters. Clinical/therapy/pharmacy/legal/safety components keep distinct authors and returns; a general checklist does not close them.
• Companion and safety: D-023 input/support/routing is not monitoring, diagnosis, human access, clinical response, completion or payment. An emergency-safe route never waits for a perfect packet or optional package; actual current-event/disclosure/recipient acceptance remains evidenced. Failed connection stays unfinished, never AI safe waiting or public-safety command.
• Permission and fulfillment: classify actual content/purpose/recipient/owner/basis/restrictions before outbound PHI; D-007 applies only to its ordinary community class. A release, appointment or outside acceptance is not furnished specialty care. Person-facing intended use and later usefulness remain separate from actual service and monthly qualification.
• Cost and continuation: extra occurrence/minutes/fees/travel/availability are O-052, not multiplied task counts or borrowed annual clinical pools. Apply base SOP due times/retries/backup and accepted extra cadence only. Preserve declined/deferred/unavailable/not-tried/unknown, pending return and independent work; do not endlessly contact for proof.

Detecting cases ENH-E01..15 and the106 source/helper links test missing/stale/conflicting/duplicated/late facts, decline, clinical subject/scope, source/population fit, physical versus digital branches, unpaid-contractor assumptions, emergency failure and actual distinct results. No field, clinical, legal, billing or Participant approval is inferred.

Service-offer interpretation#

Clinical authorship, lawful disclosure basis/restrictions, class-rule authorization, physical transmission and provider agreement are separate acts. D-033 selects automatic approved-rule sending of only the two routine provider classes, with no extra per-packet OK; any genuinely required human review still occurs. D-007's ordinary community-referral check and other classes retain their own conditions. O-008/O-014/O-021/O-030 retain actual class/authority acceptance; due/new/conflicting clinical work remains required. The treatment minimum-necessary exception does not waive other restrictions or Proxi data minimization. This changes the narrow company procedure, not runtime rule implementation or unconfirmed handling authority.

D-031 selects Philippine L1 only for manual transport of already-approved coordination provider packets and clinician-approved recommendations to authorized PCP/specialist when automated transmission is unavailable. Actual permission and required human release precede sending; clinical authorship, provider agreement, patient orders, O-014 Care Plan sending and D-007 community-referral release are not transferred. A sender choice cannot close those authority questions or create new service credit.

• D-012 settles the complete non-respite base, not an optional clinical/navigator/customer-staffing menu. Actual paid Proxi/contracted work is separate from household choice and independent outside care.
• Better preparation, useful combined contacts, practical barrier resolution and truthful closed-loop return improve required delivery; an extra label never gates or resells those obligations. GUIDE cost-sharing restrictions remain separate from company contract pricing.
• Recommendations under O-052 are not activation. Actual D-027 business scope, protected professional approval, accepted payer/provider/area/availability/backup and O-066 signing precede a promise. No numeric score, source prestige or review convergence grants authority.
• Software/AI prepares and executes only approved rule-bound work; Proxi's actual paid authorized professionals perform clinical/legal/other protected judgment. Neither generic Programme/Privacy/Quality/Data/Compliance actors nor free Participant labor may be introduced by an offer or Companion route.
• Direct furnished care, independent outside care and coordination-only have different evidence. A proposal, referral, appointment, dose reminder or routed request is not actual professional delivery or proven clinical benefit.
• Candidate coaching, preparedness and activity follow-through need a distinct added result beyond already-owed work; new cadence/minutes/fees cannot borrow the baseline budget. Person choice and decline/non-success/withdrawal remain explicit; baseline safety/access and due clinical work continue.

Manual20/24, O-052/O-053/O-PA-001 and OFF-E01..08 define these business checks. They are not a new engine/schema, clinical protocol, permission or approved price.

Workload planning interpretation#

This is a semantic accounting check, not a new workflow engine or clinical routing rule.

• Actual work once: model real occasion/reach/frequency and additional human contribution, not card counts. Shared contact/preparation/documentation is counted once; owning clinical event differs from entry channel. Unasked, attempted, pending and failed work does not become a completed service.
• Paid capacity: D-029 pays $22 per scheduled PR hour. Retain160 monthly paid hours and provisional70% productive utilization; divide active demand by usable capacity. PH coverage separately declares its contracted2,080-hour annual convention, shrinkage/reserve/lead and actual seat/concurrency scope.
• Learning/turnover: identify hires, paid learner/trainer/handover/overlap hours and inclusion in utilization. Count once; an included training budget is not a second payroll charge. Lost vacancy capacity differs from paid overlap.
• Protected contribution: no automatic RN/L2/CMO approval. The actual clinical subject/location/scope/act and funded accepting professional determine required contributions. Current valid products may be reused, not new/due work waived.
• Horizon and cohort: initial assessment, actual first-horizon annual assessment, final alignment confirmation and payment months are different clocks. Each cost pool uses its actual cohort, multiplicity and variable/step drivers; legitimately shared versus Participant-specific pools need not have identical numeric divisors.
• Unknown is not free: quote/payout unit, receiving availability, field/travel, programme job mix, physician director if applicable, release-class work and activated extras remain explicit. Provisional workload is neither approved price nor proof of answerability; care is never limited to estimated minutes.

Manual22/D-029/O-039/O-045/O-052/O-054/O-060 and WL-E01..13 carry the inputs and detecting cases. Owning service SOPs retain authority, due windows, communications, failure and completion.