ProductDraftIn reviewApprovedHemnaathSaiBoth

Implementation boundary, primary workflow, P0 capabilities, human controls, audit requirements, and pilot acceptance gates.

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# Pilot Functional Requirements ## Product boundary This FRD covers the planned cashless pre-authorization quality gate. The system prepares a review packet for a human. It never publishes a coverage or medical decision. ## Primary workflow 1. An authorized hospital operator creates a case through upload or API. 2. The intake service scans, hashes, versions, and stores each file. 3. The classifier assigns an approved document type or returns Unknown. 4. Extraction workers return typed candidate facts with confidence and page-level evidence. 5. Deterministic services normalize dates, identifiers, amounts, procedures, and medical concepts. 6. The quality gate checks required documents, mandatory fields, chronology, cross-document consistency, and the active insurer rule bundle. 7. The packet generator presents findings, unknowns, evidence, and rule lineage to a human. 8. The human verifies, corrects, overrides, or requests additional evidence. 9. Every state change and rerun is recorded for audit and replay. ## Required capabilities ### Secure intake - Portal and API intake are required for the pilot. - Email, DMS, and NHCX connectors remain adapter interfaces until a partner requires them. - Unsupported file types are quarantined, not silently dropped. - Duplicate files are detected with tenant-scoped hashes. ### Classification and extraction - The first release supports five partner-approved document types. - Classification and extraction must expose calibrated confidence. - Unknown document type and unknown field value are valid outcomes. - Every extracted value must link to document version, page, region, and snippet. ### Deterministic validation - Required-document checks use a versioned checklist selected by insurer, product, procedure family, and workflow stage. - Mandatory-field checks never infer missing values. - Cross-document comparisons use canonical normalized values and explicit tolerances. - Rule execution uses only an active, approved, version-pinned rule bundle. ### Review - Material findings open directly to source evidence. - The packet separates observed facts, deterministic results, retrieved policy context, and model-generated summary text. - Low-confidence facts, conflicting evidence, and unsupported rules route to review. - Human corrections create a new fact version and preserve the original candidate. ### Audit - Store actor, action, timestamp, tenant, case version, document version, model version, prompt version, knowledge snapshot, rule bundle, and human rationale. - A historical run must be replayable without silently using newer policy or model assets. ## Pilot acceptance gates - No material finding without evidence lineage. - No model service can call a decision or policy-publication endpoint. - No deterministic check treats unknown as pass. - No rule bundle can activate without review and golden tests. - No adverse or final decision is communicated by EvidenceGate.