Action boundary¶
| Stage | Allowed | Forbidden |
|---|---|---|
| Intake | Parse submitted synthetic case fields; preserve missing values | Infer diagnosis or fabricate evidence |
| Graph | Retrieve anchors, traverse declared policy edges, check contradictions | Add an edge at runtime or substitute model memory |
| Draft | Verbalize returned paths; flag gaps with MISSING |
Invent a citation or make a final benefit decision |
| Review | Named reviewer accepts or edits a local draft; record diff | Submit to a payer, message a prescriber, or set an approval bit |
Walk → optional verbalize → human accept/edit. The rule walk is the source of truth: it returns edge IDs, met/not_met/missing outcomes, gaps, and contradictions. The optional verbalizer may word only those results. It cannot add an edge or turn a contradiction into met; a fabricated edge makes the entire draft fail before it can enter pending_review.
Every draft sentence ends with one or more returned edge IDs or MISSING. Review remains pending_review until the reviewer endpoint records acceptance or an edit. The endpoint changes draft review status only. It has no claim-submission integration and no approval field. Audit events are append-only JSONL with case ID, tool calls, edge IDs, renderer ID (rule-walk-v1, verbalizer-stub-v1, or verbalizer-live), reviewer ID where applicable, and UTC timestamps. The UI's Submit control is disabled by design.
Do not automate yet¶
- Appeal filing: low reversibility after an external submission; payer and member rights need careful handling. Volume is unknown, so there is no demonstrated automation return.
- Peer-to-peer scheduling: contacting clinicians and handling availability reaches outside the authorized data rights and communications boundary. A mistaken message is hard to retract; volume is unmeasured.
- Diagnosis inference: inferring an unsubmitted diagnosis from labs or notes creates a clinically consequential claim and may use information beyond the payer's rights. Reviewers must supply and verify diagnoses; volume does not justify this risk.