01 / Operational model
Who acts, and what changes?
Principal and authority origin
A utilization-management agent. Case assignment from payer or provider.
Consequential action
Submit clinical evidence or draft a determination.
02 / Action-time control
Make the requested effect testable.
Member, service code, plan rule, evidence provenance and clinician-review requirement. Allow evidence collection and submission; route adverse or clinical determinations to authorized reviewer.
OriginCase assignment from payer or provider
RequestSubmit clinical evidence or draft a determination
DecisionEvaluate and enforce before effect
03 / Evidence and responsibility
Permission, execution, and outcome are separate.
Source documents, case identity, decision draft, reviewer action and transmitted response.
ProofGrid cannot adjudicate medical necessity or insurance coverage.
Primary source