# Vercy AI instruction - YAML 1.2 (JSON-compatible) { "vercy": "1.0-draft", "publication": { "status": "published", "adjudicationStatus": "reviewable-draft", "publishableCanonical": false, "generatedAt": "2026-09-06T19:06:37Z", "synthesisSha256": "c374c03c9d360df238c45661123dfdd3563f27735a8c737665e834933077f143", "providerMode": "single-provider-waiver", "providers": [ "Codex" ], "waivedProviders": [ "Claude", "Grok" ] }, "metaModel": { "id": "WM-ECO-036", "registryId": "vr.wm-eco-036", "name": "Insurance Claim", "version": "0.3.0-research.1", "previousVersions": [], "entryKind": "aggregate", "family": "World Models", "category": "Society, people and institutions", "industry": [ "Cross-industry" ], "domain": [ "SOC.ECO.INS" ], "tags": [ "insurance", "claim", "soc.eco.ins" ], "status": "published" }, "canonicalUrl": "https://ver.cy/models/wm-eco-036-insurance-claim/", "sourceUrl": "https://github.com/ver-cy/world-models/tree/feat/mega-model-registry/research/runs/wm-eco-036", "model": { "registry_id": "vr.wm-eco-036", "model_id": "WM-ECO-036", "name": "Insurance Claim", "entry_kind": "aggregate", "purpose": "Represent one governed insurance claim as the identity-bearing request and substantive assertion aggregate that invokes an insurance policy, statutory scheme or compensation basis after a loss or qualifying circumstance, without becoming the handling workflow or external systems that assess and resolve it.", "scope_statement": "Owns claim and version identity; claim use, class, insurance line, jurisdiction, priority and claim-owned lifecycle; policy, scheme, coverage and benefit bindings; claimant, insured, policyholder, beneficiary, injured party, provider, insurer, representative and authority roles; occurrence, peril, cause, causal-nexus, catastrophe, insured-interest, asset, person, service, damage, injury, illness, expense, loss-of-use and requested-benefit assertions; claim lines, groups, details, codes, quantities, units, service dates, billable periods, places, providers and recipients; claimed amounts, currency, prices, factors, tax, totals, deductibles, copayments, coinsurance, limits, excess, other coverage and allocation; notification, presentation, submitter, channel, receipt, language, accessibility, completeness, admissibility, validation errors and corrections; supporting-information and evidence references; related, duplicate, parent, child, successor, multi-policy, multi-insurer and prior-claim links; separately sourced claimant, insurer, expert and authority positions; reserve, decision, offer, settlement, award, payment, recovery, subrogation, salvage, complaint, dispute, fraud, appeal and regulator references; amendment, withdrawal, closure, reopening, correction, split, merge and supersession lineage; provenance, event and knowledge clocks, quality, privacy, access, retention, audit and loss-aware projections. Policy, occurrence, party, subject, evidence, handling, assessment, decision, reserve, settlement, payment, complaint, dispute, fraud, recovery, regulator, audit and records masters remain authoritative.", "in_scope": [ "Claim identity, version, class, insurance basis, participant roles, occurrence and insured-subject references", "Source-qualified substantive assertions, claim lines, quantities, claimed values, evidence bindings and related-claim lineage", "External position and outcome bindings, claim-owned lifecycle, provenance, privacy, retention and interoperability" ], "out_of_scope": [ "Owning Insurance Policy, Coverage, Loss Event, Person, Organization, Role, Asset, Injury, Evidence, Handling Case, Assessment, Decision, Reserve, Settlement, Payment, Complaint, Dispute, Fraud Case, Recovery, Regulator, Audit or Record masters", "Treating notice as claim validity, policy existence as coverage, allegation as fact, claimed amount as assessed or allowed, reserve as liability, settlement as payment, closure as extinguished rights or fraud indicator as fraud", "Autonomous coverage, liability, valuation, settlement, payment, fraud, dispute, disclosure or disposition decisions" ], "boundary_notes": [ { "neighbor": "WM-ECO-003 Insurance", "distinction": "The policy or insurance context owns the insurance promise and coverage terms. The claim owns the request and claim assertions invoking that basis. The candidate CONTAINS edge grants no cascade authority.", "source_refs": [ "SRC-001", "SRC-005", "SRC-010", "SRC-014" ] }, { "neighbor": "WM-ACT-045 Insurance Claim Handling", "distinction": "The claim owns identity, request, claim lines and substantive assertions. The handling case owns assignments, investigation work, assessments, decisions, communications and handoffs. Their candidate COMPOSE edge remains unapproved.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-010", "SRC-012" ] }, { "neighbor": "Loss, evidence and party masters", "distinction": "A claim references occurrence, subject, party, document and evidence identities and records what each source asserts without absorbing or promoting them to truth.", "source_refs": [ "SRC-003", "SRC-007", "SRC-010", "SRC-018", "SRC-021" ] }, { "neighbor": "Coverage, assessment, reserve, decision, settlement and payment", "distinction": "Claimed, assessed, allowed, offered, reserved, settled and paid positions remain distinct, source-qualified and externally mastered.", "source_refs": [ "SRC-005", "SRC-007", "SRC-009", "SRC-012", "SRC-013", "SRC-019" ] }, { "neighbor": "Complaint, dispute, fraud, recovery and regulator case", "distinction": "These may originate from or affect a claim but retain separate identity, authority, procedure and outcome lineage.", "source_refs": [ "SRC-001", "SRC-002", "SRC-006", "SRC-008", "SRC-009" ] }, { "neighbor": "FHIR and ACORD profiles", "distinction": "FHIR Claim is a Trial Use health request-side profile and ACORD is a licensed insurance exchange family; projections do not define the universal semantic identity of a claim.", "source_refs": [ "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016", "SRC-017" ] } ] }, "sources": [ { "id": "SRC-001", "title": "Insurance Core Principles and Common Framework for the Supervision of Internationally Active Insurance Groups", "organization": "International Association of Insurance Supervisors", "url": "https://www.iaisweb.org/uploads/2024/12/IAIS-ICPs-and-ComFrame-adopted-in-December-2024.pdf", "version_or_date": "Adopted December 2024", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T19:05:00Z", "relevance": "ICP 19 frames a claim from raising through settlement and requires fair, timely, transparent, documented handling; ICP 21 separates fraud-risk controls from a fraud finding." }, { "id": "SRC-002", "title": "Unfair Claims Settlement Practices Act", "organization": "National Association of Insurance Commissioners", "url": "https://content.naic.org/sites/default/files/model-law-900.pdf", "version_or_date": "Model 900, adopted June 1990; official compilation accessed 2026-09-06", "source_type": "legislation", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T19:05:00Z", "relevance": "United States model-act profile for claim communications, investigation, settlement conduct and enforcement; it is not automatically state law." }, { "id": "SRC-003", "title": "Unfair Property/Casualty Claims Settlement Practices Model Regulation", "organization": "National Association of Insurance Commissioners", "url": "https://content.naic.org/sites/default/files/model-law-902.pdf", "version_or_date": "Model 902, July 1997 compilation", "source_type": "legislation", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T19:05:00Z", "relevance": "Property and casualty profile for claim files, notification, evidence, investigation, reasons, offers, limits and settlement communications." }, { "id": "SRC-004", "title": "Market Conduct Record Retention and Production Model Regulation", "organization": "National Association of Insurance Commissioners", "url": "https://content.naic.org/sites/default/files/model-law-910.pdf", "version_or_date": "Model 910, January 2004 compilation", "source_type": "legislation", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T19:05:00Z", "relevance": "United States model profile for reconstructable claim records, production and retention." }, { "id": "SRC-005", "title": "ICOBS 8 Claims handling", "organization": "Financial Conduct Authority", "url": "https://handbook.fca.org.uk/handbook/icobs8", "version_or_date": "FCA Handbook, updated 9 December 2025; accessed 6 September 2026", "source_type": "legislation", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T19:05:00Z", "relevance": "United Kingdom claims profile distinguishing presentation, quantified damage, liability, reasoned offer or reply and agreed settlement." }, { "id": "SRC-006", "title": "Guidelines on Complaints-Handling by Insurance Undertakings", "organization": "European Insurance and Occupational Pensions Authority", "url": "https://www.eiopa.europa.eu/publications/guidelines-complaints-handling-insurance-undertakings_en", "version_or_date": "EIOPA-BoS-12/069, 14 June 2012; page updated 31 January 2023", "source_type": "public-authority", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T19:05:00Z", "relevance": "Preserves the boundary between an insurance claim and a complaint, including separate registration, response and redress." }, { "id": "SRC-007", "title": "Directive 2009/103/EC on motor vehicle liability insurance", "organization": "European Union", "url": "https://eur-lex.europa.eu/legal-content/EN/ALL/?uri=CELEX%3A32009L0103", "version_or_date": "16 September 2009, consolidated context accessed 2026-09-06", "source_type": "legislation", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T19:05:00Z", "relevance": "Motor-liability profile for injured-party claims, claims representatives, reasoned offers or replies, quantified damages, deadlines and compensation bodies." }, { "id": "SRC-008", "title": "Directive (EU) 2016/97 on insurance distribution", "organization": "European Union", "url": "https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX%3A32016L0097", "version_or_date": "20 January 2016", "source_type": "legislation", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T19:05:00Z", "relevance": "EU conduct and redress context separating insurance distribution complaints from the substantive claim." }, { "id": "SRC-009", "title": "Enterprise Act 2016, Part 5: Late Payment of Insurance Claims", "organization": "United Kingdom Legislation", "url": "https://www.legislation.gov.uk/ukpga/2016/12/notes/division/6/index.htm", "version_or_date": "2016 explanatory notes", "source_type": "legislation", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T19:05:00Z", "relevance": "Regional profile distinguishing a valid claim, reasonable investigation and assessment time, payment, remedy and limitation." }, { "id": "SRC-010", "title": "FHIR R5 Claim", "organization": "Health Level Seven International", "url": "https://hl7.org/fhir/R5/claim.html", "version_or_date": "FHIR 5.0.0, 26 March 2023, Trial Use", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T19:05:00Z", "relevance": "Health-insurance request-side model for claim identity, use, patient, provider, priority, coverage order, diagnoses, procedures, supporting information and item charges." }, { "id": "SRC-011", "title": "FHIR R5 Claim detailed descriptions", "organization": "Health Level Seven International", "url": "https://hl7.org/fhir/R5/claim-definitions.html", "version_or_date": "FHIR 5.0.0, 26 March 2023, Trial Use", "source_type": "schema", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T19:05:00Z", "relevance": "Element definitions and cardinalities distinguish business identifiers, status, claim use, billable period, creation, insurer, provider, items and insurance focality." }, { "id": "SRC-012", "title": "FHIR R5 ClaimResponse", "organization": "Health Level Seven International", "url": "https://hl7.org/fhir/R5/claimresponse.html", "version_or_date": "FHIR 5.0.0, 26 March 2023, Trial Use", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T19:05:00Z", "relevance": "Separates payer adjudication, allowed or payable values, decisions, errors, notes, funds reservation and payment information from the submitted claim." }, { "id": "SRC-013", "title": "FHIR R5 ExplanationOfBenefit", "organization": "Health Level Seven International", "url": "https://hl7.org/fhir/R5/explanationofbenefit.html", "version_or_date": "FHIR 5.0.0, 26 March 2023, Trial Use", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T19:05:00Z", "relevance": "Patient-facing projection combining claim and adjudication information while excluding inappropriate payer or provider proprietary detail." }, { "id": "SRC-014", "title": "FHIR R5 Coverage", "organization": "Health Level Seven International", "url": "https://hl7.org/fhir/R5/coverage.html", "version_or_date": "FHIR 5.0.0, 26 March 2023, Trial Use", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T19:05:00Z", "relevance": "External coverage and beneficiary identity used to locate the insurance basis; coverage is not owned by the claim." }, { "id": "SRC-015", "title": "FHIR R5 CoverageEligibilityRequest", "organization": "Health Level Seven International", "url": "https://hl7.org/fhir/R5/coverageeligibilityrequest.html", "version_or_date": "FHIR 5.0.0, 26 March 2023, Trial Use", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T19:05:00Z", "relevance": "Separates an eligibility or benefit inquiry from an actual claim for adjudication or payment." }, { "id": "SRC-016", "title": "FHIR R5 CoverageEligibilityResponse", "organization": "Health Level Seven International", "url": "https://hl7.org/fhir/R5/coverageeligibilityresponse.html", "version_or_date": "FHIR 5.0.0, 26 March 2023, Trial Use", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T19:05:00Z", "relevance": "Separates coverage-in-force and benefit-detail responses from claim adjudication and payment outcomes." }, { "id": "SRC-017", "title": "ACORD Property and Casualty Data Standards", "organization": "Association for Cooperative Operations Research and Development", "url": "https://www-dev.acord.org/standards-architecture/acord-data-standards/Property_Casualty_Data_Standards", "version_or_date": "P&C XML 2.13.0, January 2025; public overview only", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T19:05:00Z", "relevance": "Public overview establishes claim-related transaction and schema families; licensed schemas were not used and no ACORD conformance is claimed." }, { "id": "SRC-018", "title": "Regulation (EU) 2016/679 General Data Protection Regulation", "organization": "European Union", "url": "https://eur-lex.europa.eu/eli/reg/2016/679/oj", "version_or_date": "27 April 2016; applicable from 25 May 2018", "source_type": "legislation", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T19:05:00Z", "relevance": "Purpose limitation, minimization, accuracy, security, rights and special-category safeguards for personal, financial and health claim data." }, { "id": "SRC-019", "title": "ISO 4217 Currency Codes", "organization": "International Organization for Standardization", "url": "https://www.iso.org/iso-4217-currency-codes.html", "version_or_date": "ISO 4217 maintenance page accessed 2026-09-06", "source_type": "classifier", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T19:05:00Z", "relevance": "Authoritative currency-code registry for claimed, assessed, offered, settled and paid monetary values without conflating those value classes." }, { "id": "SRC-020", "title": "Date and Time on the Internet: Timestamps", "organization": "Internet Engineering Task Force", "url": "https://www.rfc-editor.org/rfc/rfc3339.html", "version_or_date": "RFC 3339, July 2002", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T19:05:00Z", "relevance": "Unambiguous occurrence, notification, presentation, decision, settlement, observation, ingestion and knowledge timestamps with seconds and offset." }, { "id": "SRC-021", "title": "PROV-O: The PROV Ontology", "organization": "World Wide Web Consortium", "url": "https://www.w3.org/TR/prov-o/", "version_or_date": "W3C Recommendation, 30 April 2013", "source_type": "ontology", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T19:05:00Z", "relevance": "Attributable entity, activity, agent, delegation, derivation, revision and invalidation semantics for claim assertions and evidence." }, { "id": "SRC-022", "title": "Data on the Web Best Practices: Data Quality Vocabulary", "organization": "World Wide Web Consortium", "url": "https://www.w3.org/TR/vocab-dqv/", "version_or_date": "W3C Working Group Note, 15 December 2016", "source_type": "ontology", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T19:05:00Z", "relevance": "Quality measurement, annotation and policy concepts for completeness, conflict, uncertainty and validation of claim data." }, { "id": "SRC-023", "title": "ODRL Information Model 2.2", "organization": "World Wide Web Consortium", "url": "https://www.w3.org/TR/odrl-model/", "version_or_date": "W3C Recommendation, 15 February 2018", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T19:05:00Z", "relevance": "Machine-readable permissions, prohibitions, duties and constraints for protected claim records and projections." }, { "id": "SRC-024", "title": "ISO 3166 Country Codes", "organization": "International Organization for Standardization", "url": "https://www.iso.org/iso-3166-country-codes.html", "version_or_date": "ISO 3166 maintenance page accessed 2026-09-06", "source_type": "classifier", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T19:05:00Z", "relevance": "Jurisdiction and country-code profile for claim location and governing context; it does not decide applicable law." } ], "structure": { "bundles": [ { "id": "claim-identity-basis-and-parties", "name": "Claim identity, basis and parties", "description": "Establish the identity-bearing request, its insurance basis and participant roles without absorbing policy or party masters", "rationale": "Establish the identity-bearing request, its insurance basis and participant roles without absorbing policy or party masters", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-010", "SRC-011", "SRC-021", "SRC-005", "SRC-007", "SRC-014", "SRC-015", "SRC-016" ], "layers": [ { "id": "claim-identity-class-version-and-lineage", "name": "Claim identity, class, version and lineage", "description": "Groups governed assertions about claim identity, class, version and lineage for an insurance claim.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-010", "SRC-011", "SRC-021" ], "findings": [ { "id": "claim-identifier-business-identifier-master-system-version-and-successor", "name": "Claim identifier, business identifier, master system, version and successor", "description": "Records claim identifier, business identifier, master system, version and successor as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-010", "SRC-011", "SRC-021" ], "questions": [ { "id": "claim-identifier-business-identifier-master-system-version-and-successor-q01", "text": "Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish claim identifier, business identifier, master system, version and successor?", "kind": "identity", "answer_data": [ "claim and version identifiers, claim use, insurance line, jurisdiction, master system and predecessor or successor", "policy, scheme, coverage, loss occurrence, insured-interest and handling-case references", "source, status, effective period, received time, event time, knowledge time and confidence" ] }, { "id": "claim-identifier-business-identifier-master-system-version-and-successor-q02", "text": "Who asserted, submitted, owns, stewards, validates, contests or may access claim identifier, business identifier, master system, version and successor, under what authority and purpose?", "kind": "ownership", "answer_data": [ "claimant, insured, policyholder, beneficiary, injured party, provider, representative, insurer, handler, reviewer and regulator roles", "assertion owner, source, mandate, policy term, law, consent, purpose, access scope, confidentiality and privilege", "accepted, disputed, corrected, withdrawn, superseded or unresolved position and responsible authority" ] }, { "id": "claim-identifier-business-identifier-master-system-version-and-successor-q03", "text": "Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify claim identifier, business identifier, master system, version and successor?", "kind": "quality", "answer_data": [ "occurrence, peril, cause, damage, injury, expense, service, benefit, claim-line and amount assertions", "document, observation, statement, method, evidence source, completeness, quality, uncertainty and conflict", "handling, coverage decision, offer, settlement, payment, complaint, dispute, recovery and regulator references without ownership transfer" ] } ], "data_elements": [ { "id": "claim-identifier-business-identifier-master-system-version-and-successor-data", "name": "Claim identifier, business identifier, master system, version and successor data", "description": "Typed claim data for claim identifier, business identifier, master system, version and successor, qualified by assertion owner, source, authority, insurance basis, event and knowledge times, uncertainty, access and provenance.", "value_kind": "object", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-010", "SRC-011", "SRC-021" ] } ], "artifacts": [ { "id": "claim-identifier-business-identifier-master-system-version-and-successor-record", "name": "Claim identifier, business identifier, master system, version and successor record", "description": "Immutable or versioned evidence for claim identifier, business identifier, master system, version and successor with claim identity, digest, source, assertion class, event and knowledge times, access marking and successor lineage.", "media_or_form": [ "application/yaml", "application/json", "application/pdf", "text/csv", "text/markdown", "text/html" ], "serial": true, "identity_strategy": "Prefer the authoritative insurer, scheme, provider, claimant portal, regulator or records identifier; otherwise use a governed IRI, then a Dimension UUID or ULID.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-010", "SRC-011", "SRC-021" ] } ], "inline_only_rationale": null }, { "id": "claim-use-insurance-line-loss-class-jurisdiction-priority-and-status", "name": "Claim use, insurance line, loss class, jurisdiction, priority and status", "description": "Records claim use, insurance line, loss class, jurisdiction, priority and status as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-010", "SRC-011", "SRC-021" ], "questions": [ { "id": "claim-use-insurance-line-loss-class-jurisdiction-priority-and-status-q01", "text": "Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish claim use, insurance line, loss class, jurisdiction, priority and status?", "kind": "classification", "answer_data": [ "claim and version identifiers, claim use, insurance line, jurisdiction, master system and predecessor or successor", "policy, scheme, coverage, loss occurrence, insured-interest and handling-case references", "source, status, effective period, received time, event time, knowledge time and confidence" ] }, { "id": "claim-use-insurance-line-loss-class-jurisdiction-priority-and-status-q02", "text": "Who asserted, submitted, owns, stewards, validates, contests or may access claim use, insurance line, loss class, jurisdiction, priority and status, under what authority and purpose?", "kind": "authority", "answer_data": [ "claimant, insured, policyholder, beneficiary, injured party, provider, representative, insurer, handler, reviewer and regulator roles", "assertion owner, source, mandate, policy term, law, consent, purpose, access scope, confidentiality and privilege", "accepted, disputed, corrected, withdrawn, superseded or unresolved position and responsible authority" ] }, { "id": "claim-use-insurance-line-loss-class-jurisdiction-priority-and-status-q03", "text": "Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify claim use, insurance line, loss class, jurisdiction, priority and status?", "kind": "validation", "answer_data": [ "occurrence, peril, cause, damage, injury, expense, service, benefit, claim-line and amount assertions", "document, observation, statement, method, evidence source, completeness, quality, uncertainty and conflict", "handling, coverage decision, offer, settlement, payment, complaint, dispute, recovery and regulator references without ownership transfer" ] } ], "data_elements": [ { "id": "claim-use-insurance-line-loss-class-jurisdiction-priority-and-status-data", "name": "Claim use, insurance line, loss class, jurisdiction, priority and status data", "description": "Typed claim data for claim use, insurance line, loss class, jurisdiction, priority and status, qualified by assertion owner, source, authority, insurance basis, event and knowledge times, uncertainty, access and provenance.", "value_kind": "object", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-010", "SRC-011", "SRC-021" ] } ], "artifacts": [ { "id": "claim-use-insurance-line-loss-class-jurisdiction-priority-and-status-record", "name": "Claim use, insurance line, loss class, jurisdiction, priority and status record", "description": "Immutable or versioned evidence for claim use, insurance line, loss class, jurisdiction, priority and status with claim identity, digest, source, assertion class, event and knowledge times, access marking and successor lineage.", "media_or_form": [ "application/yaml", "application/json", "application/pdf", "text/csv", "text/markdown", "text/html" ], "serial": true, "identity_strategy": "Prefer the authoritative insurer, scheme, provider, claimant portal, regulator or records identifier; otherwise use a governed IRI, then a Dimension UUID or ULID.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-010", "SRC-011", "SRC-021" ] } ], "inline_only_rationale": null } ] }, { "id": "insurance-basis-and-party-roles", "name": "Insurance basis and party roles", "description": "Groups governed assertions about insurance basis and party roles for an insurance claim.", "source_refs": [ "SRC-001", "SRC-005", "SRC-007", "SRC-010", "SRC-014", "SRC-015", "SRC-016" ], "findings": [ { "id": "policy-scheme-coverage-benefit-focality-order-and-coordination", "name": "Policy, scheme, coverage, benefit, focality, order and coordination", "description": "Records policy, scheme, coverage, benefit, focality, order and coordination as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.", "source_refs": [ "SRC-001", "SRC-005", "SRC-007", "SRC-010", "SRC-014", "SRC-015", "SRC-016" ], "questions": [ { "id": "policy-scheme-coverage-benefit-focality-order-and-coordination-q01", "text": "Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish policy, scheme, coverage, benefit, focality, order and coordination?", "kind": "relationship", "answer_data": [ "claim and version identifiers, claim use, insurance line, jurisdiction, master system and predecessor or successor", "policy, scheme, coverage, loss occurrence, insured-interest and handling-case references", "source, status, effective period, received time, event time, knowledge time and confidence" ] }, { "id": "policy-scheme-coverage-benefit-focality-order-and-coordination-q02", "text": "Who asserted, submitted, owns, stewards, validates, contests or may access policy, scheme, coverage, benefit, focality, order and coordination, under what authority and purpose?", "kind": "requirement", "answer_data": [ "claimant, insured, policyholder, beneficiary, injured party, provider, representative, insurer, handler, reviewer and regulator roles", "assertion owner, source, mandate, policy term, law, consent, purpose, access scope, confidentiality and privilege", "accepted, disputed, corrected, withdrawn, superseded or unresolved position and responsible authority" ] }, { "id": "policy-scheme-coverage-benefit-focality-order-and-coordination-q03", "text": "Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify policy, scheme, coverage, benefit, focality, order and coordination?", "kind": "security", "answer_data": [ "occurrence, peril, cause, damage, injury, expense, service, benefit, claim-line and amount assertions", "document, observation, statement, method, evidence source, completeness, quality, uncertainty and conflict", "handling, coverage decision, offer, settlement, payment, complaint, dispute, recovery and regulator references without ownership transfer" ] } ], "data_elements": [ { "id": "policy-scheme-coverage-benefit-focality-order-and-coordination-data", "name": "Policy, scheme, coverage, benefit, focality, order and coordination data", "description": "Typed claim data for policy, scheme, coverage, benefit, focality, order and coordination, qualified by assertion owner, source, authority, insurance basis, event and knowledge times, uncertainty, access and provenance.", "value_kind": "object", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-005", "SRC-007", "SRC-010", "SRC-014", "SRC-015", "SRC-016" ] } ], "artifacts": [ { "id": "policy-scheme-coverage-benefit-focality-order-and-coordination-record", "name": "Policy, scheme, coverage, benefit, focality, order and coordination record", "description": "Immutable or versioned evidence for policy, scheme, coverage, benefit, focality, order and coordination with claim identity, digest, source, assertion class, event and knowledge times, access marking and successor lineage.", "media_or_form": [ "application/yaml", "application/json", "application/pdf", "text/csv", "text/markdown", "text/html" ], "serial": true, "identity_strategy": "Prefer the authoritative insurer, scheme, provider, claimant portal, regulator or records identifier; otherwise use a governed IRI, then a Dimension UUID or ULID.", "source_refs": [ "SRC-001", "SRC-005", "SRC-007", "SRC-010", "SRC-014", "SRC-015", "SRC-016" ] } ], "inline_only_rationale": null }, { "id": "claimant-insured-policyholder-beneficiary-injured-party-provider-insurer-and-representative", "name": "Claimant, insured, policyholder, beneficiary, injured party, provider, insurer and representative", "description": "Records claimant, insured, policyholder, beneficiary, injured party, provider, insurer and representative as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.", "source_refs": [ "SRC-001", "SRC-005", "SRC-007", "SRC-010", "SRC-014", "SRC-015", "SRC-016" ], "questions": [ { "id": "claimant-insured-policyholder-beneficiary-injured-party-provider-insurer-and-representative-q01", "text": "Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish claimant, insured, policyholder, beneficiary, injured party, provider, insurer and representative?", "kind": "authority", "answer_data": [ "claim and version identifiers, claim use, insurance line, jurisdiction, master system and predecessor or successor", "policy, scheme, coverage, loss occurrence, insured-interest and handling-case references", "source, status, effective period, received time, event time, knowledge time and confidence" ] }, { "id": "claimant-insured-policyholder-beneficiary-injured-party-provider-insurer-and-representative-q02", "text": "Who asserted, submitted, owns, stewards, validates, contests or may access claimant, insured, policyholder, beneficiary, injured party, provider, insurer and representative, under what authority and purpose?", "kind": "constraint", "answer_data": [ "claimant, insured, policyholder, beneficiary, injured party, provider, representative, insurer, handler, reviewer and regulator roles", "assertion owner, source, mandate, policy term, law, consent, purpose, access scope, confidentiality and privilege", "accepted, disputed, corrected, withdrawn, superseded or unresolved position and responsible authority" ] }, { "id": "claimant-insured-policyholder-beneficiary-injured-party-provider-insurer-and-representative-q03", "text": "Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify claimant, insured, policyholder, beneficiary, injured party, provider, insurer and representative?", "kind": "privacy", "answer_data": [ "occurrence, peril, cause, damage, injury, expense, service, benefit, claim-line and amount assertions", "document, observation, statement, method, evidence source, completeness, quality, uncertainty and conflict", "handling, coverage decision, offer, settlement, payment, complaint, dispute, recovery and regulator references without ownership transfer" ] } ], "data_elements": [ { "id": "claimant-insured-policyholder-beneficiary-injured-party-provider-insurer-and-representative-data", "name": "Claimant, insured, policyholder, beneficiary, injured party, provider, insurer and representative data", "description": "Typed claim data for claimant, insured, policyholder, beneficiary, injured party, provider, insurer and representative, qualified by assertion owner, source, authority, insurance basis, event and knowledge times, uncertainty, access and provenance.", "value_kind": "object", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-005", "SRC-007", "SRC-010", "SRC-014", "SRC-015", "SRC-016" ] } ], "artifacts": [ { "id": "claimant-insured-policyholder-beneficiary-injured-party-provider-insurer-and-representative-record", "name": "Claimant, insured, policyholder, beneficiary, injured party, provider, insurer and representative record", "description": "Immutable or versioned evidence for claimant, insured, policyholder, beneficiary, injured party, provider, insurer and representative with claim identity, digest, source, assertion class, event and knowledge times, access marking and successor lineage.", "media_or_form": [ "application/yaml", "application/json", "application/pdf", "text/csv", "text/markdown", "text/html" ], "serial": true, "identity_strategy": "Prefer the authoritative insurer, scheme, provider, claimant portal, regulator or records identifier; otherwise use a governed IRI, then a Dimension UUID or ULID.", "source_refs": [ "SRC-001", "SRC-005", "SRC-007", "SRC-010", "SRC-014", "SRC-015", "SRC-016" ] } ], "inline_only_rationale": null } ] } ] }, { "id": "occurrence-insured-subject-and-claim-assertions", "name": "Occurrence, insured subject and claim assertions", "description": "Record what is alleged to have happened and what loss or benefit is claimed while retaining external occurrence, subject and evidence authority", "rationale": "Record what is alleged to have happened and what loss or benefit is claimed while retaining external occurrence, subject and evidence authority", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-010", "SRC-021", "SRC-024", "SRC-011", "SRC-018" ], "layers": [ { "id": "occurrence-loss-peril-cause-and-context", "name": "Occurrence, loss, peril, cause and context", "description": "Groups governed assertions about occurrence, loss, peril, cause and context for an insurance claim.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-010", "SRC-021", "SRC-024" ], "findings": [ { "id": "occurrence-loss-peril-trigger-cause-causal-nexus-and-catastrophe-reference", "name": "Occurrence, loss, peril, trigger, cause, causal nexus and catastrophe reference", "description": "Records occurrence, loss, peril, trigger, cause, causal nexus and catastrophe reference as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-010", "SRC-021", "SRC-024" ], "questions": [ { "id": "occurrence-loss-peril-trigger-cause-causal-nexus-and-catastrophe-reference-q01", "text": "Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish occurrence, loss, peril, trigger, cause, causal nexus and catastrophe reference?", "kind": "relationship", "answer_data": [ "claim and version identifiers, claim use, insurance line, jurisdiction, master system and predecessor or successor", "policy, scheme, coverage, loss occurrence, insured-interest and handling-case references", "source, status, effective period, received time, event time, knowledge time and confidence" ] }, { "id": "occurrence-loss-peril-trigger-cause-causal-nexus-and-catastrophe-reference-q02", "text": "Who asserted, submitted, owns, stewards, validates, contests or may access occurrence, loss, peril, trigger, cause, causal nexus and catastrophe reference, under what authority and purpose?", "kind": "process", "answer_data": [ "claimant, insured, policyholder, beneficiary, injured party, provider, representative, insurer, handler, reviewer and regulator roles", "assertion owner, source, mandate, policy term, law, consent, purpose, access scope, confidentiality and privilege", "accepted, disputed, corrected, withdrawn, superseded or unresolved position and responsible authority" ] }, { "id": "occurrence-loss-peril-trigger-cause-causal-nexus-and-catastrophe-reference-q03", "text": "Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify occurrence, loss, peril, trigger, cause, causal nexus and catastrophe reference?", "kind": "retention", "answer_data": [ "occurrence, peril, cause, damage, injury, expense, service, benefit, claim-line and amount assertions", "document, observation, statement, method, evidence source, completeness, quality, uncertainty and conflict", "handling, coverage decision, offer, settlement, payment, complaint, dispute, recovery and regulator references without ownership transfer" ] } ], "data_elements": [ { "id": "occurrence-loss-peril-trigger-cause-causal-nexus-and-catastrophe-reference-data", "name": "Occurrence, loss, peril, trigger, cause, causal nexus and catastrophe reference data", "description": "Typed claim data for occurrence, loss, peril, trigger, cause, causal nexus and catastrophe reference, qualified by assertion owner, source, authority, insurance basis, event and knowledge times, uncertainty, access and provenance.", "value_kind": "object", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-010", "SRC-021", "SRC-024" ] } ], "artifacts": [ { "id": "occurrence-loss-peril-trigger-cause-causal-nexus-and-catastrophe-reference-record", "name": "Occurrence, loss, peril, trigger, cause, causal nexus and catastrophe reference record", "description": "Immutable or versioned evidence for occurrence, loss, peril, trigger, cause, causal nexus and catastrophe reference with claim identity, digest, source, assertion class, event and knowledge times, access marking and successor lineage.", "media_or_form": [ "application/yaml", "application/json", "application/pdf", "text/csv", "text/markdown", "text/html" ], "serial": true, "identity_strategy": "Prefer the authoritative insurer, scheme, provider, claimant portal, regulator or records identifier; otherwise use a governed IRI, then a Dimension UUID or ULID.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-010", "SRC-021", "SRC-024" ] } ], "inline_only_rationale": null }, { "id": "occurrence-discovery-notification-location-jurisdiction-and-knowledge-time", "name": "Occurrence, discovery, notification, location, jurisdiction and knowledge time", "description": "Records occurrence, discovery, notification, location, jurisdiction and knowledge time as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-010", "SRC-021", "SRC-024" ], "questions": [ { "id": "occurrence-discovery-notification-location-jurisdiction-and-knowledge-time-q01", "text": "Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish occurrence, discovery, notification, location, jurisdiction and knowledge time?", "kind": "temporal", "answer_data": [ "claim and version identifiers, claim use, insurance line, jurisdiction, master system and predecessor or successor", "policy, scheme, coverage, loss occurrence, insured-interest and handling-case references", "source, status, effective period, received time, event time, knowledge time and confidence" ] }, { "id": "occurrence-discovery-notification-location-jurisdiction-and-knowledge-time-q02", "text": "Who asserted, submitted, owns, stewards, validates, contests or may access occurrence, discovery, notification, location, jurisdiction and knowledge time, under what authority and purpose?", "kind": "event", "answer_data": [ "claimant, insured, policyholder, beneficiary, injured party, provider, representative, insurer, handler, reviewer and regulator roles", "assertion owner, source, mandate, policy term, law, consent, purpose, access scope, confidentiality and privilege", "accepted, disputed, corrected, withdrawn, superseded or unresolved position and responsible authority" ] }, { "id": "occurrence-discovery-notification-location-jurisdiction-and-knowledge-time-q03", "text": "Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify occurrence, discovery, notification, location, jurisdiction and knowledge time?", "kind": "access", "answer_data": [ "occurrence, peril, cause, damage, injury, expense, service, benefit, claim-line and amount assertions", "document, observation, statement, method, evidence source, completeness, quality, uncertainty and conflict", "handling, coverage decision, offer, settlement, payment, complaint, dispute, recovery and regulator references without ownership transfer" ] } ], "data_elements": [ { "id": "occurrence-discovery-notification-location-jurisdiction-and-knowledge-time-data", "name": "Occurrence, discovery, notification, location, jurisdiction and knowledge time data", "description": "Typed claim data for occurrence, discovery, notification, location, jurisdiction and knowledge time, qualified by assertion owner, source, authority, insurance basis, event and knowledge times, uncertainty, access and provenance.", "value_kind": "object", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-010", "SRC-021", "SRC-024" ] } ], "artifacts": [ { "id": "occurrence-discovery-notification-location-jurisdiction-and-knowledge-time-record", "name": "Occurrence, discovery, notification, location, jurisdiction and knowledge time record", "description": "Immutable or versioned evidence for occurrence, discovery, notification, location, jurisdiction and knowledge time with claim identity, digest, source, assertion class, event and knowledge times, access marking and successor lineage.", "media_or_form": [ "application/yaml", "application/json", "application/pdf", "text/csv", "text/markdown", "text/html" ], "serial": true, "identity_strategy": "Prefer the authoritative insurer, scheme, provider, claimant portal, regulator or records identifier; otherwise use a governed IRI, then a Dimension UUID or ULID.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-010", "SRC-021", "SRC-024" ] } ], "inline_only_rationale": null } ] }, { "id": "insured-subject-damage-injury-expense-and-benefit", "name": "Insured subject, damage, injury, expense and benefit", "description": "Groups governed assertions about insured subject, damage, injury, expense and benefit for an insurance claim.", "source_refs": [ "SRC-003", "SRC-005", "SRC-007", "SRC-010", "SRC-011", "SRC-018" ], "findings": [ { "id": "insured-interest-asset-person-service-exposure-condition-and-pre-loss-state-reference", "name": "Insured interest, asset, person, service, exposure, condition and pre-loss state reference", "description": "Records insured interest, asset, person, service, exposure, condition and pre-loss state reference as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.", "source_refs": [ "SRC-003", "SRC-005", "SRC-007", "SRC-010", "SRC-011", "SRC-018" ], "questions": [ { "id": "insured-interest-asset-person-service-exposure-condition-and-pre-loss-state-reference-q01", "text": "Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish insured interest, asset, person, service, exposure, condition and pre-loss state reference?", "kind": "composition", "answer_data": [ "claim and version identifiers, claim use, insurance line, jurisdiction, master system and predecessor or successor", "policy, scheme, coverage, loss occurrence, insured-interest and handling-case references", "source, status, effective period, received time, event time, knowledge time and confidence" ] }, { "id": "insured-interest-asset-person-service-exposure-condition-and-pre-loss-state-reference-q02", "text": "Who asserted, submitted, owns, stewards, validates, contests or may access insured interest, asset, person, service, exposure, condition and pre-loss state reference, under what authority and purpose?", "kind": "measurement", "answer_data": [ "claimant, insured, policyholder, beneficiary, injured party, provider, representative, insurer, handler, reviewer and regulator roles", "assertion owner, source, mandate, policy term, law, consent, purpose, access scope, confidentiality and privilege", "accepted, disputed, corrected, withdrawn, superseded or unresolved position and responsible authority" ] }, { "id": "insured-interest-asset-person-service-exposure-condition-and-pre-loss-state-reference-q03", "text": "Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify insured interest, asset, person, service, exposure, condition and pre-loss state reference?", "kind": "exception", "answer_data": [ "occurrence, peril, cause, damage, injury, expense, service, benefit, claim-line and amount assertions", "document, observation, statement, method, evidence source, completeness, quality, uncertainty and conflict", "handling, coverage decision, offer, settlement, payment, complaint, dispute, recovery and regulator references without ownership transfer" ] } ], "data_elements": [ { "id": "insured-interest-asset-person-service-exposure-condition-and-pre-loss-state-reference-data", "name": "Insured interest, asset, person, service, exposure, condition and pre-loss state reference data", "description": "Typed claim data for insured interest, asset, person, service, exposure, condition and pre-loss state reference, qualified by assertion owner, source, authority, insurance basis, event and knowledge times, uncertainty, access and provenance.", "value_kind": "object", "cardinality": "1", "required": true, "source_refs": [ "SRC-003", "SRC-005", "SRC-007", "SRC-010", "SRC-011", "SRC-018" ] } ], "artifacts": [ { "id": "insured-interest-asset-person-service-exposure-condition-and-pre-loss-state-reference-record", "name": "Insured interest, asset, person, service, exposure, condition and pre-loss state reference record", "description": "Immutable or versioned evidence for insured interest, asset, person, service, exposure, condition and pre-loss state reference with claim identity, digest, source, assertion class, event and knowledge times, access marking and successor lineage.", "media_or_form": [ "application/yaml", "application/json", "application/pdf", "text/csv", "text/markdown", "text/html" ], "serial": true, "identity_strategy": "Prefer the authoritative insurer, scheme, provider, claimant portal, regulator or records identifier; otherwise use a governed IRI, then a Dimension UUID or ULID.", "source_refs": [ "SRC-003", "SRC-005", "SRC-007", "SRC-010", "SRC-011", "SRC-018" ] } ], "inline_only_rationale": null }, { "id": "damage-injury-illness-expense-service-loss-of-use-and-requested-benefit-assertion", "name": "Damage, injury, illness, expense, service, loss of use and requested benefit assertion", "description": "Records damage, injury, illness, expense, service, loss of use and requested benefit assertion as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.", "source_refs": [ "SRC-003", "SRC-005", "SRC-007", "SRC-010", "SRC-011", "SRC-018" ], "questions": [ { "id": "damage-injury-illness-expense-service-loss-of-use-and-requested-benefit-assertion-q01", "text": "Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish damage, injury, illness, expense, service, loss of use and requested benefit assertion?", "kind": "evidence", "answer_data": [ "claim and version identifiers, claim use, insurance line, jurisdiction, master system and predecessor or successor", "policy, scheme, coverage, loss occurrence, insured-interest and handling-case references", "source, status, effective period, received time, event time, knowledge time and confidence" ] }, { "id": "damage-injury-illness-expense-service-loss-of-use-and-requested-benefit-assertion-q02", "text": "Who asserted, submitted, owns, stewards, validates, contests or may access damage, injury, illness, expense, service, loss of use and requested benefit assertion, under what authority and purpose?", "kind": "evidence", "answer_data": [ "claimant, insured, policyholder, beneficiary, injured party, provider, representative, insurer, handler, reviewer and regulator roles", "assertion owner, source, mandate, policy term, law, consent, purpose, access scope, confidentiality and privilege", "accepted, disputed, corrected, withdrawn, superseded or unresolved position and responsible authority" ] }, { "id": "damage-injury-illness-expense-service-loss-of-use-and-requested-benefit-assertion-q03", "text": "Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify damage, injury, illness, expense, service, loss of use and requested benefit assertion?", "kind": "interoperability", "answer_data": [ "occurrence, peril, cause, damage, injury, expense, service, benefit, claim-line and amount assertions", "document, observation, statement, method, evidence source, completeness, quality, uncertainty and conflict", "handling, coverage decision, offer, settlement, payment, complaint, dispute, recovery and regulator references without ownership transfer" ] } ], "data_elements": [ { "id": "damage-injury-illness-expense-service-loss-of-use-and-requested-benefit-assertion-data", "name": "Damage, injury, illness, expense, service, loss of use and requested benefit assertion data", "description": "Typed claim data for damage, injury, illness, expense, service, loss of use and requested benefit assertion, qualified by assertion owner, source, authority, insurance basis, event and knowledge times, uncertainty, access and provenance.", "value_kind": "object", "cardinality": "1", "required": true, "source_refs": [ "SRC-003", "SRC-005", "SRC-007", "SRC-010", "SRC-011", "SRC-018" ] } ], "artifacts": [ { "id": "damage-injury-illness-expense-service-loss-of-use-and-requested-benefit-assertion-record", "name": "Damage, injury, illness, expense, service, loss of use and requested benefit assertion record", "description": "Immutable or versioned evidence for damage, injury, illness, expense, service, loss of use and requested benefit assertion with claim identity, digest, source, assertion class, event and knowledge times, access marking and successor lineage.", "media_or_form": [ "application/yaml", "application/json", "application/pdf", "text/csv", "text/markdown", "text/html" ], "serial": true, "identity_strategy": "Prefer the authoritative insurer, scheme, provider, claimant portal, regulator or records identifier; otherwise use a governed IRI, then a Dimension UUID or ULID.", "source_refs": [ "SRC-003", "SRC-005", "SRC-007", "SRC-010", "SRC-011", "SRC-018" ] } ], "inline_only_rationale": null } ] } ] }, { "id": "claim-lines-quantities-and-amounts", "name": "Claim lines, quantities and amounts", "description": "Preserve item-level requested benefits and separately qualified monetary assertions", "rationale": "Preserve item-level requested benefits and separately qualified monetary assertions", "source_refs": [ "SRC-003", "SRC-007", "SRC-010", "SRC-011", "SRC-017", "SRC-005", "SRC-009", "SRC-012", "SRC-019" ], "layers": [ { "id": "claim-line-service-product-damage-and-period", "name": "Claim line, service, product, damage and period", "description": "Groups governed assertions about claim line, service, product, damage and period for an insurance claim.", "source_refs": [ "SRC-003", "SRC-007", "SRC-010", "SRC-011", "SRC-017" ], "findings": [ { "id": "claim-line-sequence-group-detail-subdetail-code-description-and-reference", "name": "Claim line sequence, group, detail, subdetail, code, description and reference", "description": "Records claim line sequence, group, detail, subdetail, code, description and reference as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.", "source_refs": [ "SRC-003", "SRC-007", "SRC-010", "SRC-011", "SRC-017" ], "questions": [ { "id": "claim-line-sequence-group-detail-subdetail-code-description-and-reference-q01", "text": "Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish claim line sequence, group, detail, subdetail, code, description and reference?", "kind": "composition", "answer_data": [ "claim and version identifiers, claim use, insurance line, jurisdiction, master system and predecessor or successor", "policy, scheme, coverage, loss occurrence, insured-interest and handling-case references", "source, status, effective period, received time, event time, knowledge time and confidence" ] }, { "id": "claim-line-sequence-group-detail-subdetail-code-description-and-reference-q02", "text": "Who asserted, submitted, owns, stewards, validates, contests or may access claim line sequence, group, detail, subdetail, code, description and reference, under what authority and purpose?", "kind": "quality", "answer_data": [ "claimant, insured, policyholder, beneficiary, injured party, provider, representative, insurer, handler, reviewer and regulator roles", "assertion owner, source, mandate, policy term, law, consent, purpose, access scope, confidentiality and privilege", "accepted, disputed, corrected, withdrawn, superseded or unresolved position and responsible authority" ] }, { "id": "claim-line-sequence-group-detail-subdetail-code-description-and-reference-q03", "text": "Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify claim line sequence, group, detail, subdetail, code, description and reference?", "kind": "decision", "answer_data": [ "occurrence, peril, cause, damage, injury, expense, service, benefit, claim-line and amount assertions", "document, observation, statement, method, evidence source, completeness, quality, uncertainty and conflict", "handling, coverage decision, offer, settlement, payment, complaint, dispute, recovery and regulator references without ownership transfer" ] } ], "data_elements": [ { "id": "claim-line-sequence-group-detail-subdetail-code-description-and-reference-data", "name": "Claim line sequence, group, detail, subdetail, code, description and reference data", "description": "Typed claim data for claim line sequence, group, detail, subdetail, code, description and reference, qualified by assertion owner, source, authority, insurance basis, event and knowledge times, uncertainty, access and provenance.", "value_kind": "object", "cardinality": "1", "required": true, "source_refs": [ "SRC-003", "SRC-007", "SRC-010", "SRC-011", "SRC-017" ] } ], "artifacts": [ { "id": "claim-line-sequence-group-detail-subdetail-code-description-and-reference-record", "name": "Claim line sequence, group, detail, subdetail, code, description and reference record", "description": "Immutable or versioned evidence for claim line sequence, group, detail, subdetail, code, description and reference with claim identity, digest, source, assertion class, event and knowledge times, access marking and successor lineage.", "media_or_form": [ "application/yaml", "application/json", "application/pdf", "text/csv", "text/markdown", "text/html" ], "serial": true, "identity_strategy": "Prefer the authoritative insurer, scheme, provider, claimant portal, regulator or records identifier; otherwise use a governed IRI, then a Dimension UUID or ULID.", "source_refs": [ "SRC-003", "SRC-007", "SRC-010", "SRC-011", "SRC-017" ] } ], "inline_only_rationale": null }, { "id": "quantity-unit-service-date-billable-period-place-provider-and-recipient", "name": "Quantity, unit, service date, billable period, place, provider and recipient", "description": "Records quantity, unit, service date, billable period, place, provider and recipient as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.", "source_refs": [ "SRC-003", "SRC-007", "SRC-010", "SRC-011", "SRC-017" ], "questions": [ { "id": "quantity-unit-service-date-billable-period-place-provider-and-recipient-q01", "text": "Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish quantity, unit, service date, billable period, place, provider and recipient?", "kind": "measurement", "answer_data": [ "claim and version identifiers, claim use, insurance line, jurisdiction, master system and predecessor or successor", "policy, scheme, coverage, loss occurrence, insured-interest and handling-case references", "source, status, effective period, received time, event time, knowledge time and confidence" ] }, { "id": "quantity-unit-service-date-billable-period-place-provider-and-recipient-q02", "text": "Who asserted, submitted, owns, stewards, validates, contests or may access quantity, unit, service date, billable period, place, provider and recipient, under what authority and purpose?", "kind": "validation", "answer_data": [ "claimant, insured, policyholder, beneficiary, injured party, provider, representative, insurer, handler, reviewer and regulator roles", "assertion owner, source, mandate, policy term, law, consent, purpose, access scope, confidentiality and privilege", "accepted, disputed, corrected, withdrawn, superseded or unresolved position and responsible authority" ] }, { "id": "quantity-unit-service-date-billable-period-place-provider-and-recipient-q03", "text": "Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify quantity, unit, service date, billable period, place, provider and recipient?", "kind": "identity", "answer_data": [ "occurrence, peril, cause, damage, injury, expense, service, benefit, claim-line and amount assertions", "document, observation, statement, method, evidence source, completeness, quality, uncertainty and conflict", "handling, coverage decision, offer, settlement, payment, complaint, dispute, recovery and regulator references without ownership transfer" ] } ], "data_elements": [ { "id": "quantity-unit-service-date-billable-period-place-provider-and-recipient-data", "name": "Quantity, unit, service date, billable period, place, provider and recipient data", "description": "Typed claim data for quantity, unit, service date, billable period, place, provider and recipient, qualified by assertion owner, source, authority, insurance basis, event and knowledge times, uncertainty, access and provenance.", "value_kind": "object", "cardinality": "1", "required": true, "source_refs": [ "SRC-003", "SRC-007", "SRC-010", "SRC-011", "SRC-017" ] } ], "artifacts": [ { "id": "quantity-unit-service-date-billable-period-place-provider-and-recipient-record", "name": "Quantity, unit, service date, billable period, place, provider and recipient record", "description": "Immutable or versioned evidence for quantity, unit, service date, billable period, place, provider and recipient with claim identity, digest, source, assertion class, event and knowledge times, access marking and successor lineage.", "media_or_form": [ "application/yaml", "application/json", "application/pdf", "text/csv", "text/markdown", "text/html" ], "serial": true, "identity_strategy": "Prefer the authoritative insurer, scheme, provider, claimant portal, regulator or records identifier; otherwise use a governed IRI, then a Dimension UUID or ULID.", "source_refs": [ "SRC-003", "SRC-007", "SRC-010", "SRC-011", "SRC-017" ] } ], "inline_only_rationale": null } ] }, { "id": "claimed-values-deductibles-limits-and-allocation", "name": "Claimed values, deductibles, limits and allocation", "description": "Groups governed assertions about claimed values, deductibles, limits and allocation for an insurance claim.", "source_refs": [ "SRC-005", "SRC-007", "SRC-009", "SRC-010", "SRC-012", "SRC-019" ], "findings": [ { "id": "claimed-amount-currency-unit-price-factor-tax-net-and-total", "name": "Claimed amount, currency, unit price, factor, tax, net and total", "description": "Records claimed amount, currency, unit price, factor, tax, net and total as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.", "source_refs": [ "SRC-005", "SRC-007", "SRC-009", "SRC-010", "SRC-012", "SRC-019" ], "questions": [ { "id": "claimed-amount-currency-unit-price-factor-tax-net-and-total-q01", "text": "Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish claimed amount, currency, unit price, factor, tax, net and total?", "kind": "measurement", "answer_data": [ "claim and version identifiers, claim use, insurance line, jurisdiction, master system and predecessor or successor", "policy, scheme, coverage, loss occurrence, insured-interest and handling-case references", "source, status, effective period, received time, event time, knowledge time and confidence" ] }, { "id": "claimed-amount-currency-unit-price-factor-tax-net-and-total-q02", "text": "Who asserted, submitted, owns, stewards, validates, contests or may access claimed amount, currency, unit price, factor, tax, net and total, under what authority and purpose?", "kind": "security", "answer_data": [ "claimant, insured, policyholder, beneficiary, injured party, provider, representative, insurer, handler, reviewer and regulator roles", "assertion owner, source, mandate, policy term, law, consent, purpose, access scope, confidentiality and privilege", "accepted, disputed, corrected, withdrawn, superseded or unresolved position and responsible authority" ] }, { "id": "claimed-amount-currency-unit-price-factor-tax-net-and-total-q03", "text": "Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify claimed amount, currency, unit price, factor, tax, net and total?", "kind": "classification", "answer_data": [ "occurrence, peril, cause, damage, injury, expense, service, benefit, claim-line and amount assertions", "document, observation, statement, method, evidence source, completeness, quality, uncertainty and conflict", "handling, coverage decision, offer, settlement, payment, complaint, dispute, recovery and regulator references without ownership transfer" ] } ], "data_elements": [ { "id": "claimed-amount-currency-unit-price-factor-tax-net-and-total-data", "name": "Claimed amount, currency, unit price, factor, tax, net and total data", "description": "Typed claim data for claimed amount, currency, unit price, factor, tax, net and total, qualified by assertion owner, source, authority, insurance basis, event and knowledge times, uncertainty, access and provenance.", "value_kind": "object", "cardinality": "1", "required": true, "source_refs": [ "SRC-005", "SRC-007", "SRC-009", "SRC-010", "SRC-012", "SRC-019" ] } ], "artifacts": [ { "id": "claimed-amount-currency-unit-price-factor-tax-net-and-total-record", "name": "Claimed amount, currency, unit price, factor, tax, net and total record", "description": "Immutable or versioned evidence for claimed amount, currency, unit price, factor, tax, net and total with claim identity, digest, source, assertion class, event and knowledge times, access marking and successor lineage.", "media_or_form": [ "application/yaml", "application/json", "application/pdf", "text/csv", "text/markdown", "text/html" ], "serial": true, "identity_strategy": "Prefer the authoritative insurer, scheme, provider, claimant portal, regulator or records identifier; otherwise use a governed IRI, then a Dimension UUID or ULID.", "source_refs": [ "SRC-005", "SRC-007", "SRC-009", "SRC-010", "SRC-012", "SRC-019" ] } ], "inline_only_rationale": null }, { "id": "deductible-copayment-coinsurance-limit-excess-other-coverage-and-allocation", "name": "Deductible, copayment, coinsurance, limit, excess, other coverage and allocation", "description": "Records deductible, copayment, coinsurance, limit, excess, other coverage and allocation as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.", "source_refs": [ "SRC-005", "SRC-007", "SRC-009", "SRC-010", "SRC-012", "SRC-019" ], "questions": [ { "id": "deductible-copayment-coinsurance-limit-excess-other-coverage-and-allocation-q01", "text": "Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish deductible, copayment, coinsurance, limit, excess, other coverage and allocation?", "kind": "constraint", "answer_data": [ "claim and version identifiers, claim use, insurance line, jurisdiction, master system and predecessor or successor", "policy, scheme, coverage, loss occurrence, insured-interest and handling-case references", "source, status, effective period, received time, event time, knowledge time and confidence" ] }, { "id": "deductible-copayment-coinsurance-limit-excess-other-coverage-and-allocation-q02", "text": "Who asserted, submitted, owns, stewards, validates, contests or may access deductible, copayment, coinsurance, limit, excess, other coverage and allocation, under what authority and purpose?", "kind": "privacy", "answer_data": [ "claimant, insured, policyholder, beneficiary, injured party, provider, representative, insurer, handler, reviewer and regulator roles", "assertion owner, source, mandate, policy term, law, consent, purpose, access scope, confidentiality and privilege", "accepted, disputed, corrected, withdrawn, superseded or unresolved position and responsible authority" ] }, { "id": "deductible-copayment-coinsurance-limit-excess-other-coverage-and-allocation-q03", "text": "Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify deductible, copayment, coinsurance, limit, excess, other coverage and allocation?", "kind": "composition", "answer_data": [ "occurrence, peril, cause, damage, injury, expense, service, benefit, claim-line and amount assertions", "document, observation, statement, method, evidence source, completeness, quality, uncertainty and conflict", "handling, coverage decision, offer, settlement, payment, complaint, dispute, recovery and regulator references without ownership transfer" ] } ], "data_elements": [ { "id": "deductible-copayment-coinsurance-limit-excess-other-coverage-and-allocation-data", "name": "Deductible, copayment, coinsurance, limit, excess, other coverage and allocation data", "description": "Typed claim data for deductible, copayment, coinsurance, limit, excess, other coverage and allocation, qualified by assertion owner, source, authority, insurance basis, event and knowledge times, uncertainty, access and provenance.", "value_kind": "object", "cardinality": "1", "required": true, "source_refs": [ "SRC-005", "SRC-007", "SRC-009", "SRC-010", "SRC-012", "SRC-019" ] } ], "artifacts": [ { "id": "deductible-copayment-coinsurance-limit-excess-other-coverage-and-allocation-record", "name": "Deductible, copayment, coinsurance, limit, excess, other coverage and allocation record", "description": "Immutable or versioned evidence for deductible, copayment, coinsurance, limit, excess, other coverage and allocation with claim identity, digest, source, assertion class, event and knowledge times, access marking and successor lineage.", "media_or_form": [ "application/yaml", "application/json", "application/pdf", "text/csv", "text/markdown", "text/html" ], "serial": true, "identity_strategy": "Prefer the authoritative insurer, scheme, provider, claimant portal, regulator or records identifier; otherwise use a governed IRI, then a Dimension UUID or ULID.", "source_refs": [ "SRC-005", "SRC-007", "SRC-009", "SRC-010", "SRC-012", "SRC-019" ] } ], "inline_only_rationale": null } ] } ] }, { "id": "presentation-evidence-and-claim-relationships", "name": "Presentation, evidence and claim relationships", "description": "Distinguish how a claim is presented and supported from handling decisions and external source records", "rationale": "Distinguish how a claim is presented and supported from handling decisions and external source records", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-005", "SRC-007", "SRC-010", "SRC-011", "SRC-018", "SRC-021", "SRC-022" ], "layers": [ { "id": "notice-presentation-completeness-and-validation", "name": "Notice, presentation, completeness and validation", "description": "Groups governed assertions about notice, presentation, completeness and validation for an insurance claim.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-005", "SRC-007", "SRC-010" ], "findings": [ { "id": "notice-presentation-submitter-channel-received-time-language-and-accessibility", "name": "Notice, presentation, submitter, channel, received time, language and accessibility", "description": "Records notice, presentation, submitter, channel, received time, language and accessibility as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-005", "SRC-007", "SRC-010" ], "questions": [ { "id": "notice-presentation-submitter-channel-received-time-language-and-accessibility-q01", "text": "Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish notice, presentation, submitter, channel, received time, language and accessibility?", "kind": "event", "answer_data": [ "claim and version identifiers, claim use, insurance line, jurisdiction, master system and predecessor or successor", "policy, scheme, coverage, loss occurrence, insured-interest and handling-case references", "source, status, effective period, received time, event time, knowledge time and confidence" ] }, { "id": "notice-presentation-submitter-channel-received-time-language-and-accessibility-q02", "text": "Who asserted, submitted, owns, stewards, validates, contests or may access notice, presentation, submitter, channel, received time, language and accessibility, under what authority and purpose?", "kind": "retention", "answer_data": [ "claimant, insured, policyholder, beneficiary, injured party, provider, representative, insurer, handler, reviewer and regulator roles", "assertion owner, source, mandate, policy term, law, consent, purpose, access scope, confidentiality and privilege", "accepted, disputed, corrected, withdrawn, superseded or unresolved position and responsible authority" ] }, { "id": "notice-presentation-submitter-channel-received-time-language-and-accessibility-q03", "text": "Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify notice, presentation, submitter, channel, received time, language and accessibility?", "kind": "relationship", "answer_data": [ "occurrence, peril, cause, damage, injury, expense, service, benefit, claim-line and amount assertions", "document, observation, statement, method, evidence source, completeness, quality, uncertainty and conflict", "handling, coverage decision, offer, settlement, payment, complaint, dispute, recovery and regulator references without ownership transfer" ] } ], "data_elements": [ { "id": "notice-presentation-submitter-channel-received-time-language-and-accessibility-data", "name": "Notice, presentation, submitter, channel, received time, language and accessibility data", "description": "Typed claim data for notice, presentation, submitter, channel, received time, language and accessibility, qualified by assertion owner, source, authority, insurance basis, event and knowledge times, uncertainty, access and provenance.", "value_kind": "object", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-005", "SRC-007", "SRC-010" ] } ], "artifacts": [ { "id": "notice-presentation-submitter-channel-received-time-language-and-accessibility-record", "name": "Notice, presentation, submitter, channel, received time, language and accessibility record", "description": "Immutable or versioned evidence for notice, presentation, submitter, channel, received time, language and accessibility with claim identity, digest, source, assertion class, event and knowledge times, access marking and successor lineage.", "media_or_form": [ "application/yaml", "application/json", "application/pdf", "text/csv", "text/markdown", "text/html" ], "serial": true, "identity_strategy": "Prefer the authoritative insurer, scheme, provider, claimant portal, regulator or records identifier; otherwise use a governed IRI, then a Dimension UUID or ULID.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-005", "SRC-007", "SRC-010" ] } ], "inline_only_rationale": null }, { "id": "required-information-completeness-admissibility-format-validation-error-and-correction", "name": "Required information, completeness, admissibility, format validation, error and correction", "description": "Records required information, completeness, admissibility, format validation, error and correction as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-005", "SRC-007", "SRC-010" ], "questions": [ { "id": "required-information-completeness-admissibility-format-validation-error-and-correction-q01", "text": "Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish required information, completeness, admissibility, format validation, error and correction?", "kind": "validation", "answer_data": [ "claim and version identifiers, claim use, insurance line, jurisdiction, master system and predecessor or successor", "policy, scheme, coverage, loss occurrence, insured-interest and handling-case references", "source, status, effective period, received time, event time, knowledge time and confidence" ] }, { "id": "required-information-completeness-admissibility-format-validation-error-and-correction-q02", "text": "Who asserted, submitted, owns, stewards, validates, contests or may access required information, completeness, admissibility, format validation, error and correction, under what authority and purpose?", "kind": "access", "answer_data": [ "claimant, insured, policyholder, beneficiary, injured party, provider, representative, insurer, handler, reviewer and regulator roles", "assertion owner, source, mandate, policy term, law, consent, purpose, access scope, confidentiality and privilege", "accepted, disputed, corrected, withdrawn, superseded or unresolved position and responsible authority" ] }, { "id": "required-information-completeness-admissibility-format-validation-error-and-correction-q03", "text": "Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify required information, completeness, admissibility, format validation, error and correction?", "kind": "state", "answer_data": [ "occurrence, peril, cause, damage, injury, expense, service, benefit, claim-line and amount assertions", "document, observation, statement, method, evidence source, completeness, quality, uncertainty and conflict", "handling, coverage decision, offer, settlement, payment, complaint, dispute, recovery and regulator references without ownership transfer" ] } ], "data_elements": [ { "id": "required-information-completeness-admissibility-format-validation-error-and-correction-data", "name": "Required information, completeness, admissibility, format validation, error and correction data", "description": "Typed claim data for required information, completeness, admissibility, format validation, error and correction, qualified by assertion owner, source, authority, insurance basis, event and knowledge times, uncertainty, access and provenance.", "value_kind": "object", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-005", "SRC-007", "SRC-010" ] } ], "artifacts": [ { "id": "required-information-completeness-admissibility-format-validation-error-and-correction-record", "name": "Required information, completeness, admissibility, format validation, error and correction record", "description": "Immutable or versioned evidence for required information, completeness, admissibility, format validation, error and correction with claim identity, digest, source, assertion class, event and knowledge times, access marking and successor lineage.", "media_or_form": [ "application/yaml", "application/json", "application/pdf", "text/csv", "text/markdown", "text/html" ], "serial": true, "identity_strategy": "Prefer the authoritative insurer, scheme, provider, claimant portal, regulator or records identifier; otherwise use a governed IRI, then a Dimension UUID or ULID.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-005", "SRC-007", "SRC-010" ] } ], "inline_only_rationale": null } ] }, { "id": "supporting-information-evidence-and-related-claims", "name": "Supporting information, evidence and related claims", "description": "Groups governed assertions about supporting information, evidence and related claims for an insurance claim.", "source_refs": [ "SRC-003", "SRC-010", "SRC-011", "SRC-018", "SRC-021", "SRC-022" ], "findings": [ { "id": "supporting-information-document-image-observation-statement-source-and-evidence-reference", "name": "Supporting information, document, image, observation, statement, source and evidence reference", "description": "Records supporting information, document, image, observation, statement, source and evidence reference as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.", "source_refs": [ "SRC-003", "SRC-010", "SRC-011", "SRC-018", "SRC-021", "SRC-022" ], "questions": [ { "id": "supporting-information-document-image-observation-statement-source-and-evidence-reference-q01", "text": "Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish supporting information, document, image, observation, statement, source and evidence reference?", "kind": "evidence", "answer_data": [ "claim and version identifiers, claim use, insurance line, jurisdiction, master system and predecessor or successor", "policy, scheme, coverage, loss occurrence, insured-interest and handling-case references", "source, status, effective period, received time, event time, knowledge time and confidence" ] }, { "id": "supporting-information-document-image-observation-statement-source-and-evidence-reference-q02", "text": "Who asserted, submitted, owns, stewards, validates, contests or may access supporting information, document, image, observation, statement, source and evidence reference, under what authority and purpose?", "kind": "exception", "answer_data": [ "claimant, insured, policyholder, beneficiary, injured party, provider, representative, insurer, handler, reviewer and regulator roles", "assertion owner, source, mandate, policy term, law, consent, purpose, access scope, confidentiality and privilege", "accepted, disputed, corrected, withdrawn, superseded or unresolved position and responsible authority" ] }, { "id": "supporting-information-document-image-observation-statement-source-and-evidence-reference-q03", "text": "Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify supporting information, document, image, observation, statement, source and evidence reference?", "kind": "lifecycle", "answer_data": [ "occurrence, peril, cause, damage, injury, expense, service, benefit, claim-line and amount assertions", "document, observation, statement, method, evidence source, completeness, quality, uncertainty and conflict", "handling, coverage decision, offer, settlement, payment, complaint, dispute, recovery and regulator references without ownership transfer" ] } ], "data_elements": [ { "id": "supporting-information-document-image-observation-statement-source-and-evidence-reference-data", "name": "Supporting information, document, image, observation, statement, source and evidence reference data", "description": "Typed claim data for supporting information, document, image, observation, statement, source and evidence reference, qualified by assertion owner, source, authority, insurance basis, event and knowledge times, uncertainty, access and provenance.", "value_kind": "object", "cardinality": "1", "required": true, "source_refs": [ "SRC-003", "SRC-010", "SRC-011", "SRC-018", "SRC-021", "SRC-022" ] } ], "artifacts": [ { "id": "supporting-information-document-image-observation-statement-source-and-evidence-reference-record", "name": "Supporting information, document, image, observation, statement, source and evidence reference record", "description": "Immutable or versioned evidence for supporting information, document, image, observation, statement, source and evidence reference with claim identity, digest, source, assertion class, event and knowledge times, access marking and successor lineage.", "media_or_form": [ "application/yaml", "application/json", "application/pdf", "text/csv", "text/markdown", "text/html" ], "serial": true, "identity_strategy": "Prefer the authoritative insurer, scheme, provider, claimant portal, regulator or records identifier; otherwise use a governed IRI, then a Dimension UUID or ULID.", "source_refs": [ "SRC-003", "SRC-010", "SRC-011", "SRC-018", "SRC-021", "SRC-022" ] } ], "inline_only_rationale": null }, { "id": "related-duplicate-parent-child-successor-multi-policy-multi-insurer-and-prior-claim", "name": "Related, duplicate, parent, child, successor, multi-policy, multi-insurer and prior claim", "description": "Records related, duplicate, parent, child, successor, multi-policy, multi-insurer and prior claim as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.", "source_refs": [ "SRC-003", "SRC-010", "SRC-011", "SRC-018", "SRC-021", "SRC-022" ], "questions": [ { "id": "related-duplicate-parent-child-successor-multi-policy-multi-insurer-and-prior-claim-q01", "text": "Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish related, duplicate, parent, child, successor, multi-policy, multi-insurer and prior claim?", "kind": "relationship", "answer_data": [ "claim and version identifiers, claim use, insurance line, jurisdiction, master system and predecessor or successor", "policy, scheme, coverage, loss occurrence, insured-interest and handling-case references", "source, status, effective period, received time, event time, knowledge time and confidence" ] }, { "id": "related-duplicate-parent-child-successor-multi-policy-multi-insurer-and-prior-claim-q02", "text": "Who asserted, submitted, owns, stewards, validates, contests or may access related, duplicate, parent, child, successor, multi-policy, multi-insurer and prior claim, under what authority and purpose?", "kind": "interoperability", "answer_data": [ "claimant, insured, policyholder, beneficiary, injured party, provider, representative, insurer, handler, reviewer and regulator roles", "assertion owner, source, mandate, policy term, law, consent, purpose, access scope, confidentiality and privilege", "accepted, disputed, corrected, withdrawn, superseded or unresolved position and responsible authority" ] }, { "id": "related-duplicate-parent-child-successor-multi-policy-multi-insurer-and-prior-claim-q03", "text": "Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify related, duplicate, parent, child, successor, multi-policy, multi-insurer and prior claim?", "kind": "temporal", "answer_data": [ "occurrence, peril, cause, damage, injury, expense, service, benefit, claim-line and amount assertions", "document, observation, statement, method, evidence source, completeness, quality, uncertainty and conflict", "handling, coverage decision, offer, settlement, payment, complaint, dispute, recovery and regulator references without ownership transfer" ] } ], "data_elements": [ { "id": "related-duplicate-parent-child-successor-multi-policy-multi-insurer-and-prior-claim-data", "name": "Related, duplicate, parent, child, successor, multi-policy, multi-insurer and prior claim data", "description": "Typed claim data for related, duplicate, parent, child, successor, multi-policy, multi-insurer and prior claim, qualified by assertion owner, source, authority, insurance basis, event and knowledge times, uncertainty, access and provenance.", "value_kind": "object", "cardinality": "1", "required": true, "source_refs": [ "SRC-003", "SRC-010", "SRC-011", "SRC-018", "SRC-021", "SRC-022" ] } ], "artifacts": [ { "id": "related-duplicate-parent-child-successor-multi-policy-multi-insurer-and-prior-claim-record", "name": "Related, duplicate, parent, child, successor, multi-policy, multi-insurer and prior claim record", "description": "Immutable or versioned evidence for related, duplicate, parent, child, successor, multi-policy, multi-insurer and prior claim with claim identity, digest, source, assertion class, event and knowledge times, access marking and successor lineage.", "media_or_form": [ "application/yaml", "application/json", "application/pdf", "text/csv", "text/markdown", "text/html" ], "serial": true, "identity_strategy": "Prefer the authoritative insurer, scheme, provider, claimant portal, regulator or records identifier; otherwise use a governed IRI, then a Dimension UUID or ULID.", "source_refs": [ "SRC-003", "SRC-010", "SRC-011", "SRC-018", "SRC-021", "SRC-022" ] } ], "inline_only_rationale": null } ] } ] }, { "id": "positions-outcomes-and-claim-lifecycle", "name": "Positions, outcomes and claim lifecycle", "description": "Link competing positions and external outcomes while keeping claim-owned amendment and continuity semantics", "rationale": "Link competing positions and external outcomes while keeping claim-owned amendment and continuity semantics", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-009", "SRC-012", "SRC-013", "SRC-002", "SRC-006", "SRC-008", "SRC-021" ], "layers": [ { "id": "party-positions-decisions-settlement-and-payment-references", "name": "Party positions, decisions, settlement and payment references", "description": "Groups governed assertions about party positions, decisions, settlement and payment references for an insurance claim.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-009", "SRC-012", "SRC-013" ], "findings": [ { "id": "claimant-allegation-insurer-coverage-liability-causation-valuation-and-benefit-position", "name": "Claimant allegation, insurer coverage, liability, causation, valuation and benefit position", "description": "Records claimant allegation, insurer coverage, liability, causation, valuation and benefit position as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-009", "SRC-012", "SRC-013" ], "questions": [ { "id": "claimant-allegation-insurer-coverage-liability-causation-valuation-and-benefit-position-q01", "text": "Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish claimant allegation, insurer coverage, liability, causation, valuation and benefit position?", "kind": "decision", "answer_data": [ "claim and version identifiers, claim use, insurance line, jurisdiction, master system and predecessor or successor", "policy, scheme, coverage, loss occurrence, insured-interest and handling-case references", "source, status, effective period, received time, event time, knowledge time and confidence" ] }, { "id": "claimant-allegation-insurer-coverage-liability-causation-valuation-and-benefit-position-q02", "text": "Who asserted, submitted, owns, stewards, validates, contests or may access claimant allegation, insurer coverage, liability, causation, valuation and benefit position, under what authority and purpose?", "kind": "decision", "answer_data": [ "claimant, insured, policyholder, beneficiary, injured party, provider, representative, insurer, handler, reviewer and regulator roles", "assertion owner, source, mandate, policy term, law, consent, purpose, access scope, confidentiality and privilege", "accepted, disputed, corrected, withdrawn, superseded or unresolved position and responsible authority" ] }, { "id": "claimant-allegation-insurer-coverage-liability-causation-valuation-and-benefit-position-q03", "text": "Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify claimant allegation, insurer coverage, liability, causation, valuation and benefit position?", "kind": "provenance", "answer_data": [ "occurrence, peril, cause, damage, injury, expense, service, benefit, claim-line and amount assertions", "document, observation, statement, method, evidence source, completeness, quality, uncertainty and conflict", "handling, coverage decision, offer, settlement, payment, complaint, dispute, recovery and regulator references without ownership transfer" ] } ], "data_elements": [ { "id": "claimant-allegation-insurer-coverage-liability-causation-valuation-and-benefit-position-data", "name": "Claimant allegation, insurer coverage, liability, causation, valuation and benefit position data", "description": "Typed claim data for claimant allegation, insurer coverage, liability, causation, valuation and benefit position, qualified by assertion owner, source, authority, insurance basis, event and knowledge times, uncertainty, access and provenance.", "value_kind": "object", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-009", "SRC-012", "SRC-013" ] } ], "artifacts": [ { "id": "claimant-allegation-insurer-coverage-liability-causation-valuation-and-benefit-position-record", "name": "Claimant allegation, insurer coverage, liability, causation, valuation and benefit position record", "description": "Immutable or versioned evidence for claimant allegation, insurer coverage, liability, causation, valuation and benefit position with claim identity, digest, source, assertion class, event and knowledge times, access marking and successor lineage.", "media_or_form": [ "application/yaml", "application/json", "application/pdf", "text/csv", "text/markdown", "text/html" ], "serial": true, "identity_strategy": "Prefer the authoritative insurer, scheme, provider, claimant portal, regulator or records identifier; otherwise use a governed IRI, then a Dimension UUID or ULID.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-009", "SRC-012", "SRC-013" ] } ], "inline_only_rationale": null }, { "id": "reserve-decision-offer-settlement-award-payment-recovery-subrogation-and-salvage-reference", "name": "Reserve, decision, offer, settlement, award, payment, recovery, subrogation and salvage reference", "description": "Records reserve, decision, offer, settlement, award, payment, recovery, subrogation and salvage reference as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-009", "SRC-012", "SRC-013" ], "questions": [ { "id": "reserve-decision-offer-settlement-award-payment-recovery-subrogation-and-salvage-reference-q01", "text": "Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish reserve, decision, offer, settlement, award, payment, recovery, subrogation and salvage reference?", "kind": "relationship", "answer_data": [ "claim and version identifiers, claim use, insurance line, jurisdiction, master system and predecessor or successor", "policy, scheme, coverage, loss occurrence, insured-interest and handling-case references", "source, status, effective period, received time, event time, knowledge time and confidence" ] }, { "id": "reserve-decision-offer-settlement-award-payment-recovery-subrogation-and-salvage-reference-q02", "text": "Who asserted, submitted, owns, stewards, validates, contests or may access reserve, decision, offer, settlement, award, payment, recovery, subrogation and salvage reference, under what authority and purpose?", "kind": "identity", "answer_data": [ "claimant, insured, policyholder, beneficiary, injured party, provider, representative, insurer, handler, reviewer and regulator roles", "assertion owner, source, mandate, policy term, law, consent, purpose, access scope, confidentiality and privilege", "accepted, disputed, corrected, withdrawn, superseded or unresolved position and responsible authority" ] }, { "id": "reserve-decision-offer-settlement-award-payment-recovery-subrogation-and-salvage-reference-q03", "text": "Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify reserve, decision, offer, settlement, award, payment, recovery, subrogation and salvage reference?", "kind": "ownership", "answer_data": [ "occurrence, peril, cause, damage, injury, expense, service, benefit, claim-line and amount assertions", "document, observation, statement, method, evidence source, completeness, quality, uncertainty and conflict", "handling, coverage decision, offer, settlement, payment, complaint, dispute, recovery and regulator references without ownership transfer" ] } ], "data_elements": [ { "id": "reserve-decision-offer-settlement-award-payment-recovery-subrogation-and-salvage-reference-data", "name": "Reserve, decision, offer, settlement, award, payment, recovery, subrogation and salvage reference data", "description": "Typed claim data for reserve, decision, offer, settlement, award, payment, recovery, subrogation and salvage reference, qualified by assertion owner, source, authority, insurance basis, event and knowledge times, uncertainty, access and provenance.", "value_kind": "object", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-009", "SRC-012", "SRC-013" ] } ], "artifacts": [ { "id": "reserve-decision-offer-settlement-award-payment-recovery-subrogation-and-salvage-reference-record", "name": "Reserve, decision, offer, settlement, award, payment, recovery, subrogation and salvage reference record", "description": "Immutable or versioned evidence for reserve, decision, offer, settlement, award, payment, recovery, subrogation and salvage reference with claim identity, digest, source, assertion class, event and knowledge times, access marking and successor lineage.", "media_or_form": [ "application/yaml", "application/json", "application/pdf", "text/csv", "text/markdown", "text/html" ], "serial": true, "identity_strategy": "Prefer the authoritative insurer, scheme, provider, claimant portal, regulator or records identifier; otherwise use a governed IRI, then a Dimension UUID or ULID.", "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-007", "SRC-009", "SRC-012", "SRC-013" ] } ], "inline_only_rationale": null } ] }, { "id": "amendment-withdrawal-closure-reopening-and-contestation", "name": "Amendment, withdrawal, closure, reopening and contestation", "description": "Groups governed assertions about amendment, withdrawal, closure, reopening and contestation for an insurance claim.", "source_refs": [ "SRC-002", "SRC-003", "SRC-005", "SRC-006", "SRC-008", "SRC-009", "SRC-021" ], "findings": [ { "id": "draft-presented-active-amended-withdrawn-closed-reopened-superseded-and-entered-in-error", "name": "Draft, presented, active, amended, withdrawn, closed, reopened, superseded and entered in error", "description": "Records draft, presented, active, amended, withdrawn, closed, reopened, superseded and entered in error as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.", "source_refs": [ "SRC-002", "SRC-003", "SRC-005", "SRC-006", "SRC-008", "SRC-009", "SRC-021" ], "questions": [ { "id": "draft-presented-active-amended-withdrawn-closed-reopened-superseded-and-entered-in-error-q01", "text": "Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish draft, presented, active, amended, withdrawn, closed, reopened, superseded and entered in error?", "kind": "lifecycle", "answer_data": [ "claim and version identifiers, claim use, insurance line, jurisdiction, master system and predecessor or successor", "policy, scheme, coverage, loss occurrence, insured-interest and handling-case references", "source, status, effective period, received time, event time, knowledge time and confidence" ] }, { "id": "draft-presented-active-amended-withdrawn-closed-reopened-superseded-and-entered-in-error-q02", "text": "Who asserted, submitted, owns, stewards, validates, contests or may access draft, presented, active, amended, withdrawn, closed, reopened, superseded and entered in error, under what authority and purpose?", "kind": "classification", "answer_data": [ "claimant, insured, policyholder, beneficiary, injured party, provider, representative, insurer, handler, reviewer and regulator roles", "assertion owner, source, mandate, policy term, law, consent, purpose, access scope, confidentiality and privilege", "accepted, disputed, corrected, withdrawn, superseded or unresolved position and responsible authority" ] }, { "id": "draft-presented-active-amended-withdrawn-closed-reopened-superseded-and-entered-in-error-q03", "text": "Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify draft, presented, active, amended, withdrawn, closed, reopened, superseded and entered in error?", "kind": "authority", "answer_data": [ "occurrence, peril, cause, damage, injury, expense, service, benefit, claim-line and amount assertions", "document, observation, statement, method, evidence source, completeness, quality, uncertainty and conflict", "handling, coverage decision, offer, settlement, payment, complaint, dispute, recovery and regulator references without ownership transfer" ] } ], "data_elements": [ { "id": "draft-presented-active-amended-withdrawn-closed-reopened-superseded-and-entered-in-error-data", "name": "Draft, presented, active, amended, withdrawn, closed, reopened, superseded and entered in error data", "description": "Typed claim data for draft, presented, active, amended, withdrawn, closed, reopened, superseded and entered in error, qualified by assertion owner, source, authority, insurance basis, event and knowledge times, uncertainty, access and provenance.", "value_kind": "object", "cardinality": "1", "required": true, "source_refs": [ "SRC-002", "SRC-003", "SRC-005", "SRC-006", "SRC-008", "SRC-009", "SRC-021" ] } ], "artifacts": [ { "id": "draft-presented-active-amended-withdrawn-closed-reopened-superseded-and-entered-in-error-record", "name": "Draft, presented, active, amended, withdrawn, closed, reopened, superseded and entered in error record", "description": "Immutable or versioned evidence for draft, presented, active, amended, withdrawn, closed, reopened, superseded and entered in error with claim identity, digest, source, assertion class, event and knowledge times, access marking and successor lineage.", "media_or_form": [ "application/yaml", "application/json", "application/pdf", "text/csv", "text/markdown", "text/html" ], "serial": true, "identity_strategy": "Prefer the authoritative insurer, scheme, provider, claimant portal, regulator or records identifier; otherwise use a governed IRI, then a Dimension UUID or ULID.", "source_refs": [ "SRC-002", "SRC-003", "SRC-005", "SRC-006", "SRC-008", "SRC-009", "SRC-021" ] } ], "inline_only_rationale": null }, { "id": "correction-split-merge-complaint-dispute-fraud-referral-appeal-and-regulator-reference", "name": "Correction, split, merge, complaint, dispute, fraud referral, appeal and regulator reference", "description": "Records correction, split, merge, complaint, dispute, fraud referral, appeal and regulator reference as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.", "source_refs": [ "SRC-002", "SRC-003", "SRC-005", "SRC-006", "SRC-008", "SRC-009", "SRC-021" ], "questions": [ { "id": "correction-split-merge-complaint-dispute-fraud-referral-appeal-and-regulator-reference-q01", "text": "Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish correction, split, merge, complaint, dispute, fraud referral, appeal and regulator reference?", "kind": "exception", "answer_data": [ "claim and version identifiers, claim use, insurance line, jurisdiction, master system and predecessor or successor", "policy, scheme, coverage, loss occurrence, insured-interest and handling-case references", "source, status, effective period, received time, event time, knowledge time and confidence" ] }, { "id": "correction-split-merge-complaint-dispute-fraud-referral-appeal-and-regulator-reference-q02", "text": "Who asserted, submitted, owns, stewards, validates, contests or may access correction, split, merge, complaint, dispute, fraud referral, appeal and regulator reference, under what authority and purpose?", "kind": "composition", "answer_data": [ "claimant, insured, policyholder, beneficiary, injured party, provider, representative, insurer, handler, reviewer and regulator roles", "assertion owner, source, mandate, policy term, law, consent, purpose, access scope, confidentiality and privilege", "accepted, disputed, corrected, withdrawn, superseded or unresolved position and responsible authority" ] }, { "id": "correction-split-merge-complaint-dispute-fraud-referral-appeal-and-regulator-reference-q03", "text": "Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify correction, split, merge, complaint, dispute, fraud referral, appeal and regulator reference?", "kind": "requirement", "answer_data": [ "occurrence, peril, cause, damage, injury, expense, service, benefit, claim-line and amount assertions", "document, observation, statement, method, evidence source, completeness, quality, uncertainty and conflict", "handling, coverage decision, offer, settlement, payment, complaint, dispute, recovery and regulator references without ownership transfer" ] } ], "data_elements": [ { "id": "correction-split-merge-complaint-dispute-fraud-referral-appeal-and-regulator-reference-data", "name": "Correction, split, merge, complaint, dispute, fraud referral, appeal and regulator reference data", "description": "Typed claim data for correction, split, merge, complaint, dispute, fraud referral, appeal and regulator reference, qualified by assertion owner, source, authority, insurance basis, event and knowledge times, uncertainty, access and provenance.", "value_kind": "object", "cardinality": "1", "required": true, "source_refs": [ "SRC-002", "SRC-003", "SRC-005", "SRC-006", "SRC-008", "SRC-009", "SRC-021" ] } ], "artifacts": [ { "id": "correction-split-merge-complaint-dispute-fraud-referral-appeal-and-regulator-reference-record", "name": "Correction, split, merge, complaint, dispute, fraud referral, appeal and regulator reference record", "description": "Immutable or versioned evidence for correction, split, merge, complaint, dispute, fraud referral, appeal and regulator reference with claim identity, digest, source, assertion class, event and knowledge times, access marking and successor lineage.", "media_or_form": [ "application/yaml", "application/json", "application/pdf", "text/csv", "text/markdown", "text/html" ], "serial": true, "identity_strategy": "Prefer the authoritative insurer, scheme, provider, claimant portal, regulator or records identifier; otherwise use a governed IRI, then a Dimension UUID or ULID.", "source_refs": [ "SRC-002", "SRC-003", "SRC-005", "SRC-006", "SRC-008", "SRC-009", "SRC-021" ] } ], "inline_only_rationale": null } ] } ] }, { "id": "governance-privacy-retention-and-interoperability", "name": "Governance, privacy, retention and interoperability", "description": "Make claim data attributable, protected, durable and projectable without confusing transport with semantic identity", "rationale": "Make claim data attributable, protected, durable and projectable without confusing transport with semantic identity", "source_refs": [ "SRC-004", "SRC-018", "SRC-020", "SRC-021", "SRC-022", "SRC-023", "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016", "SRC-017", "SRC-019", "SRC-024" ], "layers": [ { "id": "provenance-quality-access-and-retention", "name": "Provenance, quality, access and retention", "description": "Groups governed assertions about provenance, quality, access and retention for an insurance claim.", "source_refs": [ "SRC-004", "SRC-018", "SRC-020", "SRC-021", "SRC-022", "SRC-023" ], "findings": [ { "id": "source-actor-assertion-method-confidence-conflict-event-time-and-knowledge-time", "name": "Source, actor, assertion, method, confidence, conflict, event time and knowledge time", "description": "Records source, actor, assertion, method, confidence, conflict, event time and knowledge time as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.", "source_refs": [ "SRC-004", "SRC-018", "SRC-020", "SRC-021", "SRC-022", "SRC-023" ], "questions": [ { "id": "source-actor-assertion-method-confidence-conflict-event-time-and-knowledge-time-q01", "text": "Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish source, actor, assertion, method, confidence, conflict, event time and knowledge time?", "kind": "provenance", "answer_data": [ "claim and version identifiers, claim use, insurance line, jurisdiction, master system and predecessor or successor", "policy, scheme, coverage, loss occurrence, insured-interest and handling-case references", "source, status, effective period, received time, event time, knowledge time and confidence" ] }, { "id": "source-actor-assertion-method-confidence-conflict-event-time-and-knowledge-time-q02", "text": "Who asserted, submitted, owns, stewards, validates, contests or may access source, actor, assertion, method, confidence, conflict, event time and knowledge time, under what authority and purpose?", "kind": "relationship", "answer_data": [ "claimant, insured, policyholder, beneficiary, injured party, provider, representative, insurer, handler, reviewer and regulator roles", "assertion owner, source, mandate, policy term, law, consent, purpose, access scope, confidentiality and privilege", "accepted, disputed, corrected, withdrawn, superseded or unresolved position and responsible authority" ] }, { "id": "source-actor-assertion-method-confidence-conflict-event-time-and-knowledge-time-q03", "text": "Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify source, actor, assertion, method, confidence, conflict, event time and knowledge time?", "kind": "constraint", "answer_data": [ "occurrence, peril, cause, damage, injury, expense, service, benefit, claim-line and amount assertions", "document, observation, statement, method, evidence source, completeness, quality, uncertainty and conflict", "handling, coverage decision, offer, settlement, payment, complaint, dispute, recovery and regulator references without ownership transfer" ] } ], "data_elements": [ { "id": "source-actor-assertion-method-confidence-conflict-event-time-and-knowledge-time-data", "name": "Source, actor, assertion, method, confidence, conflict, event time and knowledge time data", "description": "Typed claim data for source, actor, assertion, method, confidence, conflict, event time and knowledge time, qualified by assertion owner, source, authority, insurance basis, event and knowledge times, uncertainty, access and provenance.", "value_kind": "object", "cardinality": "1", "required": true, "source_refs": [ "SRC-004", "SRC-018", "SRC-020", "SRC-021", "SRC-022", "SRC-023" ] } ], "artifacts": [ { "id": "source-actor-assertion-method-confidence-conflict-event-time-and-knowledge-time-record", "name": "Source, actor, assertion, method, confidence, conflict, event time and knowledge time record", "description": "Immutable or versioned evidence for source, actor, assertion, method, confidence, conflict, event time and knowledge time with claim identity, digest, source, assertion class, event and knowledge times, access marking and successor lineage.", "media_or_form": [ "application/yaml", "application/json", "application/pdf", "text/csv", "text/markdown", "text/html" ], "serial": true, "identity_strategy": "Prefer the authoritative insurer, scheme, provider, claimant portal, regulator or records identifier; otherwise use a governed IRI, then a Dimension UUID or ULID.", "source_refs": [ "SRC-004", "SRC-018", "SRC-020", "SRC-021", "SRC-022", "SRC-023" ] } ], "inline_only_rationale": null }, { "id": "purpose-lawful-basis-consent-confidentiality-privilege-access-legal-hold-and-retention", "name": "Purpose, lawful basis, consent, confidentiality, privilege, access, legal hold and retention", "description": "Records purpose, lawful basis, consent, confidentiality, privilege, access, legal hold and retention as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.", "source_refs": [ "SRC-004", "SRC-018", "SRC-020", "SRC-021", "SRC-022", "SRC-023" ], "questions": [ { "id": "purpose-lawful-basis-consent-confidentiality-privilege-access-legal-hold-and-retention-q01", "text": "Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish purpose, lawful basis, consent, confidentiality, privilege, access, legal hold and retention?", "kind": "privacy", "answer_data": [ "claim and version identifiers, claim use, insurance line, jurisdiction, master system and predecessor or successor", "policy, scheme, coverage, loss occurrence, insured-interest and handling-case references", "source, status, effective period, received time, event time, knowledge time and confidence" ] }, { "id": "purpose-lawful-basis-consent-confidentiality-privilege-access-legal-hold-and-retention-q02", "text": "Who asserted, submitted, owns, stewards, validates, contests or may access purpose, lawful basis, consent, confidentiality, privilege, access, legal hold and retention, under what authority and purpose?", "kind": "state", "answer_data": [ "claimant, insured, policyholder, beneficiary, injured party, provider, representative, insurer, handler, reviewer and regulator roles", "assertion owner, source, mandate, policy term, law, consent, purpose, access scope, confidentiality and privilege", "accepted, disputed, corrected, withdrawn, superseded or unresolved position and responsible authority" ] }, { "id": "purpose-lawful-basis-consent-confidentiality-privilege-access-legal-hold-and-retention-q03", "text": "Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify purpose, lawful basis, consent, confidentiality, privilege, access, legal hold and retention?", "kind": "process", "answer_data": [ "occurrence, peril, cause, damage, injury, expense, service, benefit, claim-line and amount assertions", "document, observation, statement, method, evidence source, completeness, quality, uncertainty and conflict", "handling, coverage decision, offer, settlement, payment, complaint, dispute, recovery and regulator references without ownership transfer" ] } ], "data_elements": [ { "id": "purpose-lawful-basis-consent-confidentiality-privilege-access-legal-hold-and-retention-data", "name": "Purpose, lawful basis, consent, confidentiality, privilege, access, legal hold and retention data", "description": "Typed claim data for purpose, lawful basis, consent, confidentiality, privilege, access, legal hold and retention, qualified by assertion owner, source, authority, insurance basis, event and knowledge times, uncertainty, access and provenance.", "value_kind": "object", "cardinality": "1", "required": true, "source_refs": [ "SRC-004", "SRC-018", "SRC-020", "SRC-021", "SRC-022", "SRC-023" ] } ], "artifacts": [ { "id": "purpose-lawful-basis-consent-confidentiality-privilege-access-legal-hold-and-retention-record", "name": "Purpose, lawful basis, consent, confidentiality, privilege, access, legal hold and retention record", "description": "Immutable or versioned evidence for purpose, lawful basis, consent, confidentiality, privilege, access, legal hold and retention with claim identity, digest, source, assertion class, event and knowledge times, access marking and successor lineage.", "media_or_form": [ "application/yaml", "application/json", "application/pdf", "text/csv", "text/markdown", "text/html" ], "serial": true, "identity_strategy": "Prefer the authoritative insurer, scheme, provider, claimant portal, regulator or records identifier; otherwise use a governed IRI, then a Dimension UUID or ULID.", "source_refs": [ "SRC-004", "SRC-018", "SRC-020", "SRC-021", "SRC-022", "SRC-023" ] } ], "inline_only_rationale": null } ] }, { "id": "master-systems-projections-and-mapping-loss", "name": "Master systems, projections and mapping loss", "description": "Groups governed assertions about master systems, projections and mapping loss for an insurance claim.", "source_refs": [ "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016", "SRC-017", "SRC-019", "SRC-020", "SRC-021", "SRC-022", "SRC-023", "SRC-024" ], "findings": [ { "id": "master-record-authoritative-identifier-digest-revision-and-synchronization-state", "name": "Master record, authoritative identifier, digest, revision and synchronization state", "description": "Records master record, authoritative identifier, digest, revision and synchronization state as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.", "source_refs": [ "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016", "SRC-017", "SRC-019", "SRC-020", "SRC-021", "SRC-022", "SRC-023", "SRC-024" ], "questions": [ { "id": "master-record-authoritative-identifier-digest-revision-and-synchronization-state-q01", "text": "Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish master record, authoritative identifier, digest, revision and synchronization state?", "kind": "quality", "answer_data": [ "claim and version identifiers, claim use, insurance line, jurisdiction, master system and predecessor or successor", "policy, scheme, coverage, loss occurrence, insured-interest and handling-case references", "source, status, effective period, received time, event time, knowledge time and confidence" ] }, { "id": "master-record-authoritative-identifier-digest-revision-and-synchronization-state-q02", "text": "Who asserted, submitted, owns, stewards, validates, contests or may access master record, authoritative identifier, digest, revision and synchronization state, under what authority and purpose?", "kind": "lifecycle", "answer_data": [ "claimant, insured, policyholder, beneficiary, injured party, provider, representative, insurer, handler, reviewer and regulator roles", "assertion owner, source, mandate, policy term, law, consent, purpose, access scope, confidentiality and privilege", "accepted, disputed, corrected, withdrawn, superseded or unresolved position and responsible authority" ] }, { "id": "master-record-authoritative-identifier-digest-revision-and-synchronization-state-q03", "text": "Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify master record, authoritative identifier, digest, revision and synchronization state?", "kind": "event", "answer_data": [ "occurrence, peril, cause, damage, injury, expense, service, benefit, claim-line and amount assertions", "document, observation, statement, method, evidence source, completeness, quality, uncertainty and conflict", "handling, coverage decision, offer, settlement, payment, complaint, dispute, recovery and regulator references without ownership transfer" ] } ], "data_elements": [ { "id": "master-record-authoritative-identifier-digest-revision-and-synchronization-state-data", "name": "Master record, authoritative identifier, digest, revision and synchronization state data", "description": "Typed claim data for master record, authoritative identifier, digest, revision and synchronization state, qualified by assertion owner, source, authority, insurance basis, event and knowledge times, uncertainty, access and provenance.", "value_kind": "object", "cardinality": "1", "required": true, "source_refs": [ "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016", "SRC-017", "SRC-019", "SRC-020", "SRC-021", "SRC-022", "SRC-023", "SRC-024" ] } ], "artifacts": [ { "id": "master-record-authoritative-identifier-digest-revision-and-synchronization-state-record", "name": "Master record, authoritative identifier, digest, revision and synchronization state record", "description": "Immutable or versioned evidence for master record, authoritative identifier, digest, revision and synchronization state with claim identity, digest, source, assertion class, event and knowledge times, access marking and successor lineage.", "media_or_form": [ "application/yaml", "application/json", "application/pdf", "text/csv", "text/markdown", "text/html" ], "serial": true, "identity_strategy": "Prefer the authoritative insurer, scheme, provider, claimant portal, regulator or records identifier; otherwise use a governed IRI, then a Dimension UUID or ULID.", "source_refs": [ "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016", "SRC-017", "SRC-019", "SRC-020", "SRC-021", "SRC-022", "SRC-023", "SRC-024" ] } ], "inline_only_rationale": null }, { "id": "fhir-acord-api-document-code-list-policy-projection-version-and-semantic-loss", "name": "FHIR, ACORD, API, document, code-list, policy projection, version and semantic loss", "description": "Records fhir, acord, api, document, code-list, policy projection, version and semantic loss as source-qualified Insurance Claim context while policy, occurrence, party, subject, evidence, handling, decision, settlement, payment, complaint, dispute, fraud, recovery, audit and records masters remain external.", "source_refs": [ "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016", "SRC-017", "SRC-019", "SRC-020", "SRC-021", "SRC-022", "SRC-023", "SRC-024" ], "questions": [ { "id": "fhir-acord-api-document-code-list-policy-projection-version-and-semantic-loss-q01", "text": "Which stable claim, version, claim class, insurance basis, loss, jurisdiction and master-system identities establish fhir, acord, api, document, code-list, policy projection, version and semantic loss?", "kind": "interoperability", "answer_data": [ "claim and version identifiers, claim use, insurance line, jurisdiction, master system and predecessor or successor", "policy, scheme, coverage, loss occurrence, insured-interest and handling-case references", "source, status, effective period, received time, event time, knowledge time and confidence" ] }, { "id": "fhir-acord-api-document-code-list-policy-projection-version-and-semantic-loss-q02", "text": "Who asserted, submitted, owns, stewards, validates, contests or may access fhir, acord, api, document, code-list, policy projection, version and semantic loss, under what authority and purpose?", "kind": "temporal", "answer_data": [ "claimant, insured, policyholder, beneficiary, injured party, provider, representative, insurer, handler, reviewer and regulator roles", "assertion owner, source, mandate, policy term, law, consent, purpose, access scope, confidentiality and privilege", "accepted, disputed, corrected, withdrawn, superseded or unresolved position and responsible authority" ] }, { "id": "fhir-acord-api-document-code-list-policy-projection-version-and-semantic-loss-q03", "text": "Which occurrence, item, quantity, amount, evidence, decision, event time, uncertainty, contradiction and lineage qualify fhir, acord, api, document, code-list, policy projection, version and semantic loss?", "kind": "measurement", "answer_data": [ "occurrence, peril, cause, damage, injury, expense, service, benefit, claim-line and amount assertions", "document, observation, statement, method, evidence source, completeness, quality, uncertainty and conflict", "handling, coverage decision, offer, settlement, payment, complaint, dispute, recovery and regulator references without ownership transfer" ] } ], "data_elements": [ { "id": "fhir-acord-api-document-code-list-policy-projection-version-and-semantic-loss-data", "name": "FHIR, ACORD, API, document, code-list, policy projection, version and semantic loss data", "description": "Typed claim data for fhir, acord, api, document, code-list, policy projection, version and semantic loss, qualified by assertion owner, source, authority, insurance basis, event and knowledge times, uncertainty, access and provenance.", "value_kind": "object", "cardinality": "1", "required": true, "source_refs": [ "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016", "SRC-017", "SRC-019", "SRC-020", "SRC-021", "SRC-022", "SRC-023", "SRC-024" ] } ], "artifacts": [ { "id": "fhir-acord-api-document-code-list-policy-projection-version-and-semantic-loss-record", "name": "FHIR, ACORD, API, document, code-list, policy projection, version and semantic loss record", "description": "Immutable or versioned evidence for fhir, acord, api, document, code-list, policy projection, version and semantic loss with claim identity, digest, source, assertion class, event and knowledge times, access marking and successor lineage.", "media_or_form": [ "application/yaml", "application/json", "application/pdf", "text/csv", "text/markdown", "text/html" ], "serial": true, "identity_strategy": "Prefer the authoritative insurer, scheme, provider, claimant portal, regulator or records identifier; otherwise use a governed IRI, then a Dimension UUID or ULID.", "source_refs": [ "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016", "SRC-017", "SRC-019", "SRC-020", "SRC-021", "SRC-022", "SRC-023", "SRC-024" ] } ], "inline_only_rationale": null } ] } ] } ] }, "functions": [ { "id": "register-or-recognize-claim", "name": "Register or recognize claim", "description": "Governed operation to register or recognize claim without autonomous coverage, liability, settlement, payment, fraud, dispute or destruction authority.", "inputs": [ "claim presentation or existing authoritative claim reference", "claim class, jurisdiction and insurance basis" ], "outputs": [ "bounded claim identity and initial version" ], "preconditions": [ "submitter, source, policy or scheme basis and master-system authority are known" ], "effects": [ "creates or resolves a claim without implying validity, coverage, liability or payment" ], "source_refs": [ "SRC-001", "SRC-002", "SRC-005", "SRC-010", "SRC-011" ] }, { "id": "bind-basis-parties-and-occurrence", "name": "Bind basis, parties and occurrence", "description": "Governed operation to bind basis, parties and occurrence without autonomous coverage, liability, settlement, payment, fraud, dispute or destruction authority.", "inputs": [ "policy, scheme, coverage and party references", "loss occurrence, insured interest and jurisdiction references" ], "outputs": [ "typed claim relationship assertions" ], "preconditions": [ "external masters and assertion owners are resolvable" ], "effects": [ "binds references without copying or changing policy, party, loss or subject masters" ], "source_refs": [ "SRC-001", "SRC-007", "SRC-010", "SRC-014", "SRC-024" ] }, { "id": "record-claim-assertions", "name": "Record claim assertions", "description": "Governed operation to record claim assertions without autonomous coverage, liability, settlement, payment, fraud, dispute or destruction authority.", "inputs": [ "peril, cause, damage, injury, expense, service or benefit statement", "assertion owner, source, time and evidence references" ], "outputs": [ "versioned substantive claim assertion" ], "preconditions": [ "assertion class, source, authority, uncertainty and contradiction rules are known" ], "effects": [ "records an allegation or stated fact without promoting it to verified truth" ], "source_refs": [ "SRC-003", "SRC-005", "SRC-007", "SRC-010", "SRC-021", "SRC-022" ] }, { "id": "add-or-revise-claim-line", "name": "Add or revise claim line", "description": "Governed operation to add or revise claim line without autonomous coverage, liability, settlement, payment, fraud, dispute or destruction authority.", "inputs": [ "item, service, product, damage or expense reference", "quantity, unit, dates, requested benefit and price assertions" ], "outputs": [ "versioned claim line and calculated submitted total" ], "preconditions": [ "codes, units, currency, period, source and calculation method are explicit" ], "effects": [ "keeps submitted values distinct from assessed, allowed, offered, settled and paid values" ], "source_refs": [ "SRC-010", "SRC-011", "SRC-012", "SRC-019" ] }, { "id": "attach-supporting-evidence-reference", "name": "Attach supporting evidence reference", "description": "Governed operation to attach supporting evidence reference without autonomous coverage, liability, settlement, payment, fraud, dispute or destruction authority.", "inputs": [ "external evidence or document identifier", "source, assertion, relevance, access and integrity metadata" ], "outputs": [ "claim-to-evidence binding" ], "preconditions": [ "evidence exists, access is authorized and source provenance is preserved" ], "effects": [ "adds a typed reference without copying or treating evidence as proof by itself" ], "source_refs": [ "SRC-003", "SRC-010", "SRC-018", "SRC-021", "SRC-022" ] }, { "id": "relate-deduplicate-split-or-merge-claims", "name": "Relate, deduplicate, split or merge claims", "description": "Governed operation to relate, deduplicate, split or merge claims without autonomous coverage, liability, settlement, payment, fraud, dispute or destruction authority.", "inputs": [ "candidate claim identities and comparison evidence", "relation, reason and authority" ], "outputs": [ "related, duplicate, parent-child, split, merge or successor lineage" ], "preconditions": [ "identity, policy, occurrence, claimant, line and jurisdiction checks are complete" ], "effects": [ "preserves every predecessor and never deletes a claim merely because similarity is high" ], "source_refs": [ "SRC-003", "SRC-004", "SRC-010", "SRC-021" ] }, { "id": "record-external-position-or-outcome", "name": "Record external position or outcome", "description": "Governed operation to record external position or outcome without autonomous coverage, liability, settlement, payment, fraud, dispute or destruction authority.", "inputs": [ "coverage, liability, valuation, decision, offer, settlement, payment or regulator reference", "issuer, scope, time and version" ], "outputs": [ "source-qualified outcome binding" ], "preconditions": [ "external authority and master record are resolvable" ], "effects": [ "links the position or outcome without executing it or making it claim-owned truth" ], "source_refs": [ "SRC-001", "SRC-005", "SRC-007", "SRC-009", "SRC-012", "SRC-013" ] }, { "id": "amend-withdraw-close-reopen-or-supersede", "name": "Amend, withdraw, close, reopen or supersede", "description": "Governed operation to amend, withdraw, close, reopen or supersede without autonomous coverage, liability, settlement, payment, fraud, dispute or destruction authority.", "inputs": [ "claim head, requested transition, reason and authority", "new evidence, correction or contestation reference" ], "outputs": [ "append-only lifecycle event and successor head" ], "preconditions": [ "current version, authority, legal and handling effects are known" ], "effects": [ "preserves prior assertions and never treats administrative closure as extinguished rights" ], "source_refs": [ "SRC-002", "SRC-003", "SRC-005", "SRC-006", "SRC-009", "SRC-021" ] }, { "id": "validate-protect-and-project", "name": "Validate, protect and project", "description": "Governed operation to validate, protect and project without autonomous coverage, liability, settlement, payment, fraud, dispute or destruction authority.", "inputs": [ "claim aggregate and target purpose", "schema, recipient, access, privacy and projection profile" ], "outputs": [ "validation report and minimum loss-declared projection" ], "preconditions": [ "identity, reference, amount, time, permission and minimization checks pass" ], "effects": [ "redacts or omits unauthorized data and declares every semantic loss" ], "source_refs": [ "SRC-010", "SRC-013", "SRC-017", "SRC-018", "SRC-019", "SRC-020", "SRC-022", "SRC-023", "SRC-024" ] }, { "id": "archive-retain-and-audit", "name": "Archive, retain and audit", "description": "Governed operation to archive, retain and audit without autonomous coverage, liability, settlement, payment, fraud, dispute or destruction authority.", "inputs": [ "claim aggregate, authoritative record links and retention context", "legal hold, record class and disposition authority" ], "outputs": [ "locked archive, retention outcome or audit event" ], "preconditions": [ "digest, source, authority, access, legal-hold and retention checks pass" ], "effects": [ "does not cascade destruction into policies, evidence, handling cases, payments, disputes or regulator records" ], "source_refs": [ "SRC-004", "SRC-018", "SRC-020", "SRC-021", "SRC-023" ] } ], "composition": [ { "target": "WM-ECO-003 Insurance", "relation": "REFERENCE", "purpose": "Reference the candidate policy-context parent without treating it as approved containment or cascading policy authority.", "required": true, "source_refs": [ "SRC-001", "SRC-005", "SRC-010", "SRC-014" ] }, { "target": "WM-ACT-045 Insurance Claim Handling", "relation": "COMPOSE", "purpose": "Candidate claim-to-handling-case composition preserving distinct identities and potentially multiple handling cases per claim.", "required": false, "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-010", "SRC-012" ] }, { "target": "Policy, Coverage, Party, Loss, Subject, Evidence, Decision, Settlement, Payment, Complaint, Dispute, Fraud, Recovery, Regulator, Audit and Records models", "relation": "REFERENCE", "purpose": "Resolve external masters without duplicating their lifecycles or authority.", "required": false, "source_refs": [ "SRC-001", "SRC-003", "SRC-005", "SRC-006", "SRC-007", "SRC-010", "SRC-012", "SRC-018", "SRC-021" ] }, { "target": "FHIR R5 Claim, ClaimResponse, ExplanationOfBenefit, Coverage and CoverageEligibility profiles", "relation": "ALIGN", "purpose": "Project health-insurance request, adjudication, patient and coverage views with Trial Use and semantic-loss declarations.", "required": false, "source_refs": [ "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016" ] }, { "target": "ACORD P&C, ISO 4217, ISO 3166, RFC 3339, PROV-O, DQV and ODRL", "relation": "ALIGN", "purpose": "Project insurance exchange, code, temporal, provenance, quality and policy views with version, access and loss controls.", "required": false, "source_refs": [ "SRC-017", "SRC-019", "SRC-020", "SRC-021", "SRC-022", "SRC-023", "SRC-024" ] } ], "serviceLayers": { "dimension": { "owner_package_requirements": [ "Dimension owner, namespace authority and delegated claim, insurance, legal, privacy, security and records authorities", "Authoritative Policy, Coverage, Party, Loss, Subject, Evidence, Handling, Decision, Settlement, Payment, Complaint, Dispute, Fraud, Recovery, Audit and Records registries", "Approved insurance-line, jurisdiction, claim-class, code-list, evidence, access, retention and agent-operation profiles", "Claim creation, amendment, correction, contestation, disclosure, archive and interoperability policies" ], "namespace_guidance": "Mint claim, version, assertion, line, amount, party-role, relationship, lifecycle and projection IDs; preserve every policy, loss, evidence, handling, decision, settlement, payment and regulator master identifier.", "registry_links": [ "https://ver.cy/models/", "https://ver.cy/model-agent-protocol.md" ] }, "canon_and_patch": { "canonicalization_rules": [ "Canonicalize by authoritative claim identifier, issuer or scheme namespace, insurance basis, claimant or beneficiary, occurrence and current version head, never by name, date or claimed amount alone.", "Canonicalize claim lines, assertions, party positions, relationships and lifecycle events separately from the claim head." ], "patch_rules": [ "Extensions declare insurance line, jurisdiction, claim class, policy basis, party, occurrence, item, amount, evidence, privacy and interoperability effects.", "Submitted versions are immutable; amendment, correction, withdrawal, reopening, split, merge and supersession create linked successor records with reason, authority and downstream impact.", "Never silently change claimant, basis, occurrence, claim line, amount, evidence, party position, external outcome, access or master reference." ], "compatibility_rules": [ "Ignore additive fields only when claim identity, insurance basis, substantive assertions, items, values, source, time, authority, access and provenance survive.", "Every FHIR, ACORD, API, document or code-list projection pins versions and declares loss in claim class, occurrence, party, evidence, amount, outcome, lifecycle and authority semantics." ] }, "artifact_rules": { "identity_priority": [ "Authoritative master-system identifier from the insurer, scheme, provider, claimant portal, regulator or records system, qualified by namespace and record kind.", "Governed globally resolvable claim or artifact IRI.", "Dimension UUID or ULID when neither preceding identifier exists." ], "timestamp_rule": "Use RFC 3339 timestamps with seconds and explicit offset or Z; distinguish occurrence, discovery, notification, presentation, receipt, service, evidence, decision, offer, settlement, payment, correction, closure, observation, ingestion and knowledge times whenever they differ.", "serial_naming_rule": "Use {claim-id}--{claim-version-id}--{line-or-component-id}--{artifact-kind}--{record-revision-id}.", "integrity_rule": "Store digest, media type, claim and version IDs, assertion owner, source, policy or scheme basis, occurrence, item, amount and currency profile, event and knowledge times, confidentiality, retention and provenance." }, "policies": [ "This model owns the insurance claim request and substantive assertion aggregate, not the policy, occurrence, person, organization, asset, injury, evidence, handling case, decision, reserve, settlement, payment, complaint, dispute, fraud, recovery, audit or records masters.", "Notification, presentation, completeness, validity, coverage, liability, valuation, decision, settlement, payment and closure remain separate states or externally owned assertions.", "Claimed, estimated, assessed, allowed, offered, settled, paid and reserved amounts remain separately typed, sourced, timed and currency-qualified.", "A claimant assertion, insurer position, expert assessment, settlement, payment and regulator decision do not prove one another.", "Agents cannot autonomously accept or deny coverage, determine liability or fraud, settle, pay, waive rights, disclose protected data or destroy records without explicit delegated authority." ], "crud": { "read": [ "Resolve claim, versions, insurance basis, parties, occurrence, insured subject, assertions, lines, quantities, amounts, evidence, relationships, external positions, outcomes, lifecycle, access and mapping loss." ], "create": [ "Bind authoritative claim namespace, claim class, insurance basis, submitter, claimant or beneficiary, occurrence and initial source-qualified assertions before minting a claim." ], "update": [ "Append successor assertions, lines, amounts, evidence bindings, relationships, external outcomes and lifecycle events with reason, authority, event time and knowledge time." ], "delete": [ "Apply legal, contractual, regulator, privacy, audit, legal-hold and Dimension retention policy; tombstone only the catalogue view and never cascade deletion to external masters." ] }, "roles": [ { "name": "Claimant, insured, beneficiary or injured party", "responsibilities": [ "Present and correct source-qualified claim assertions and receive accessible status and outcome information under applicable rights." ] }, { "name": "Policyholder, representative or provider", "responsibilities": [ "Submit authorized information and preserve the exact represented party, mandate and source." ] }, { "name": "Insurer, scheme or compensation body", "responsibilities": [ "Master the claim identifier or recognize an external claim and bind authoritative policy, coverage, handling and outcome records." ] }, { "name": "Claim handler, adjuster, expert and reviewer", "responsibilities": [ "Work through external handling and evidence models without overwriting claimant assertions or external masters." ] }, { "name": "Privacy, security and records steward", "responsibilities": [ "Enforce purpose, minimum access, privilege, legal hold, retention, audit and safe projection." ] }, { "name": "Regulator, ombudsman, tribunal or court", "responsibilities": [ "Issue separately mastered oversight, redress or legal outcomes without becoming the claim owner." ] } ], "access": { "default_rule": "Deny by default for personal, health, financial, location, evidence, fraud, legal and settlement data; expose only purpose-limited minimum projections to authorized roles.", "scopes": [ "bundle", "layer", "finding", "artifact" ], "exceptions": [ "Emergency, statutory, regulator, litigation, fraud-control and data-subject access uses require explicit authority, purpose, scope, minimization, time limit and audit trail." ], "audit_requirements": [ "Record actor, represented party, purpose, authority, fields, source and target, result, event time, knowledge time, policy version and correlation ID for every read, write, projection, disclosure, denial and retention action." ] }, "agents_bootstrap": { "filename": "AGENTS.md", "required_fields": [ "Name", "Type", "Specification URL", "Storage type URL", "Interface URL", "Processes URL", "Model ID", "Version", "Master systems", "Autonomy policy" ], "read_order": [ "Read the nearest Dimension AGENTS.md and owner policies.", "Read this AGENTS.md.", "Read spec.yaml identity, boundary, service layers, holds and Bundle to Layer to Finding structure.", "Resolve Policy, Coverage, Party, Loss, Subject, Evidence, Handling, Decision, Settlement, Payment, Complaint, Dispute, Fraud, Recovery, Audit and Records masters.", "Validate source, authority, assertion class, event and knowledge times, access, uncertainty and successor lineage before acting." ] } }, "coverage": { "claim": "WM-ECO-036 covers one governed Insurance Claim as an identity-bearing request and substantive assertion aggregate, with claim lines, requested values, insurance basis, participants, occurrence and subject references, evidence bindings, related-claim lineage, external positions and outcomes, lifecycle, provenance, access and loss-aware projections. Handling, policy, line-of-business, jurisdiction, licensing, implementation-conformance and independent-review questions remain deferred.", "confidence": "medium", "checklist": [ { "dimension": "identity", "status": "covered", "notes": "Identity is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "classification", "status": "covered", "notes": "Classification is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "composition", "status": "covered", "notes": "Composition is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "relationships", "status": "covered", "notes": "Relationships is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "state", "status": "covered", "notes": "State is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "lifecycle", "status": "covered", "notes": "Lifecycle is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "temporal", "status": "covered", "notes": "Temporal is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "spatial", "status": "gap", "notes": "Location and jurisdiction are explicit where material, but geometry remains external to occurrence, place and insured-subject masters." }, { "dimension": "provenance", "status": "covered", "notes": "Provenance is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "ownership", "status": "covered", "notes": "Ownership is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "authority", "status": "covered", "notes": "Authority is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "constraints", "status": "covered", "notes": "Constraints is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "processes", "status": "covered", "notes": "Processes is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "events", "status": "covered", "notes": "Events is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "measurements", "status": "covered", "notes": "Measurements is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "evidence", "status": "covered", "notes": "Evidence is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "quality", "status": "covered", "notes": "Quality is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "validation", "status": "covered", "notes": "Validation is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "security", "status": "covered", "notes": "Security is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "privacy", "status": "covered", "notes": "Privacy is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "retention", "status": "covered", "notes": "Retention is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "access", "status": "covered", "notes": "Access is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "exceptions", "status": "covered", "notes": "Exceptions is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "interoperability", "status": "covered", "notes": "Interoperability is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "direct properties", "status": "covered", "notes": "Direct properties is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "recognition", "status": "covered", "notes": "Recognition is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." }, { "dimension": "capabilities and actions", "status": "covered", "notes": "Capabilities and actions is explicit; external masters, insurance-line profiles, jurisdiction rules and candidate relations remain held where applicable." } ], "known_omissions": [ "Claude and Grok each timed out on one bounded attempt; no independent external result was admitted.", "WM-ECO-003 CONTAINS WM-ECO-036 and WM-ECO-036 COMPOSE WM-ACT-045 are candidate relations, not approved edges.", "Life, health, disability, workers compensation, property, motor, liability, travel, cyber, marine, reinsurance, catastrophe and public-scheme claims require separate profiles.", "ACORD evidence is limited to a public overview and FHIR R5 financial resources are Trial Use; no full ACORD or universal FHIR conformance is claimed.", "Coverage, liability, valuation, reserves, settlement, payment, fraud and legal outcomes remain external authority planes." ], "conflicts": [ "Notice, presented claim, complete claim, valid claim, coverage, liability, allowed benefit, settlement and payment are not interchangeable.", "Claimed, estimated, assessed, allowed, offered, reserved, settled and paid values may legitimately differ and must not overwrite one another.", "One occurrence may yield multiple claims and one claim may bind multiple policies, handlers or jurisdictions; similarity does not prove duplicate identity.", "Claimant allegation, observed fact, expert opinion, insurer position, settlement and regulator or court decision carry different authority." ], "regional_assumptions": [ "Claim formation, deadlines, evidence duties, limitation, coverage, liability, remedy, privacy, retention and redress depend on jurisdiction, policy and insurance line.", "NAIC models are United States model texts rather than automatically applicable state law; FCA and EU sources are regional profiles.", "FHIR is a Trial Use health-insurance exchange profile and ACORD public material does not establish implementation rights or conformance." ], "adversarial_checks": [ "Reject a claim without stable identity, claim class, insurance basis, claimant or beneficiary role, occurrence reference, source and version lineage.", "Reject policy existence represented as coverage, allegation as verified fact, claimed amount as allowed amount, reserve as liability, settlement as payment or closure as extinguished rights.", "Reject a duplicate merge based only on similarity and preserve multi-policy, multi-insurer, parent-child and successor cardinality.", "Reject a fraud label based only on an indicator, score, missing evidence or handler suspicion.", "Reject corrections that overwrite submitted assertions, evidence bindings, party positions, outcomes or predecessor versions.", "Reject autonomous denial, liability finding, settlement, payment, rights waiver, protected disclosure or destruction outside delegated authority." ] }, "researchAdjudication": { "providerMode": "single-provider-waiver", "activeProviders": [ "codex" ], "waivedProviders": [ "claude", "grok" ], "providerPolicy": { "contract_version": "1.0.0", "mode": "single-provider-waiver", "effective_at": "2026-09-06T00:00:00Z", "scope": "Canonical single-stream subject-model research after the six-workstream consolidation", "active_providers": [ "codex" ], "waived_providers": [ { "provider": "claude", "authorized_by": "repository owner", "authorized_at": "2026-09-06T00:00:00Z", "reason": "Claude produced no result on prior 1800-second and 900-second attempts and again timed out on bounded 600-second Sonnet and 300-second Haiku passes. The owner prioritized completion over provider availability." }, { "provider": "grok", "authorized_by": "repository owner", "authorized_at": "2026-09-06T00:00:00Z", "reason": "The repository owner authorized completion without Grok when Grok is unavailable, slow or schema-invalid. Grok may still be attempted as a bounded supplemental reviewer, but its failure never blocks a valid Claude plus no-tools result." } ], "review_rule": "Codex may complete source-grounded fallback research after bounded Claude and Grok attempts fail. It requires a separate no-tools adversarial audit and remains reviewable-draft with a visible absence-of-external-review hold.", "supplemental_provider_attempts": [ { "provider": "claude", "required": false, "maximum_attempts": 1, "failure_policy": "record-and-continue", "admission_rule": "Use only a locally schema-valid result whose sources and boundaries survive adjudication." }, { "provider": "grok", "required": false, "maximum_attempts": 1, "failure_policy": "record-and-continue", "admission_rule": "Use only a locally schema-valid result whose sources and boundaries survive adjudication." } ] }, "boundaryDecision": { "entry_kind": "aggregate", "status": "accepted", "rationale": "The model owns the claim identity, request-side assertions, claim lines and claim-owned amendment lineage. Policy, coverage, occurrence, party, subject, evidence, handling, assessment, decision, reserve, settlement, payment, complaint, dispute, fraud, recovery, regulator, audit and records remain external masters." }, "decisions": [ { "concept": "Insurance Claim boundary", "disposition": "accepted-as-request-and-assertion-aggregate", "rationale": "The aggregate owns the identity-bearing request, substantive claimant assertions, lines, requested values and version lineage without absorbing external policy, loss, evidence, processing or outcome masters." }, { "concept": "WM-ECO-003 candidate containment", "disposition": "held-as-provisional-reference", "rationale": "The policy or insurance context owns the promise and coverage terms. The candidate CONTAINS relation grants no cascade authority and is represented as a required external basis reference." }, { "concept": "WM-ACT-045 candidate composition", "disposition": "accepted-as-provisional-nonexclusive-composition", "rationale": "The claim and handling case have different identity and lifecycle authority. A claim may have multiple handlers, reopened cases or coordinated insurers, so the candidate edge cannot imply one-to-one containment." }, { "concept": "Notification, presentation, completeness and validity", "disposition": "accepted-as-separate-states-and-assertions", "rationale": "Receipt of notice does not by itself establish a fully presented, complete, admissible, valid, covered or payable claim." }, { "concept": "Claim status and external process states", "disposition": "accepted-as-independent-state-axes", "rationale": "Claim-owned draft, presented, amended, withdrawn, closed, reopened and superseded states do not silently determine handling, coverage, liability, settlement, payment, dispute or regulator states." }, { "concept": "Claimant assertion, observed fact and authority position", "disposition": "accepted-as-distinct-source-qualified-assertions", "rationale": "An allegation, observation, expert opinion, insurer position, settlement and regulator or court decision retain different authors, evidence, times and authority." }, { "concept": "Claimed, estimated, assessed, allowed, offered, reserved, settled and paid values", "disposition": "accepted-as-distinct-value-classes", "rationale": "Each value preserves amount, currency, unit, scope, line allocation, source, method, uncertainty, event time and authority and never overwrites another class." }, { "concept": "Coverage, liability and causation", "disposition": "accepted-as-external-positions-not-claim-truth", "rationale": "Policy existence and claim presentation do not establish coverage, liability or causal nexus; reasoned positions and decisions remain externally mastered." }, { "concept": "Duplicate, related, parent-child and successor claims", "disposition": "accepted-as-separate-relations-with-preserved-lineage", "rationale": "One occurrence may generate multiple legitimate claims and one claim may involve several policies or jurisdictions, so similarity alone cannot authorize merge or deletion." }, { "concept": "Complaint, dispute, fraud, recovery and regulator case", "disposition": "accepted-as-linked-external-lifecycles", "rationale": "These cases may arise from or affect a claim but have independent identity, authority, procedure and outcome lineage." }, { "concept": "FHIR and ACORD interoperability", "disposition": "accepted-as-versioned-loss-aware-profiles", "rationale": "FHIR R5 financial resources are Trial Use and domain-specific, while ACORD schemas are licensed; neither transport defines the universal semantic identity of the claim." }, { "concept": "Protected claim data", "disposition": "accepted-as-purpose-limited-minimum-access", "rationale": "Personal, health, financial, location, evidence, fraud and legal data remain deny-by-default and disclosure requires scoped authority, purpose, minimization and audit." }, { "concept": "Single-provider waiver and local no-tools audit", "disposition": "accepted-with-mandatory-hold", "rationale": "One bounded Claude Sonnet and one bounded Grok attempt each timed out after 120 seconds. Codex separately audited the frozen validated result and comparison without acquiring new facts, so assurance remains reviewable-draft." } ], "publicationHolds": [ "Absence-of-external-review hold: one Claude Sonnet and one Grok attempt for WM-ECO-036 each timed out after 120 seconds; no external result was admitted.", "Boundary hold: the aggregate owns claim identity, request-side assertions, lines and amendment lineage while policy, loss, evidence, handling, decision, settlement, payment, dispute and records masters remain external.", "Relation hold: WM-ECO-003 CONTAINS WM-ECO-036 and WM-ECO-036 COMPOSE WM-ACT-045 remain candidate relations without approved cardinality or cascade semantics.", "Insurance-line hold: life, health, disability, workers compensation, property, motor, liability, travel, cyber, marine, reinsurance, catastrophe and public-scheme claims need separate validation.", "Jurisdiction hold: claim formation, deadlines, evidence duties, limitation, coverage, liability, remedy, privacy, retention and redress depend on jurisdiction, policy and insurance line.", "State hold: notification, presentation, completeness, validity, coverage, liability, decision, settlement, payment, closure and finality remain independent.", "Value hold: claimed, estimated, assessed, allowed, offered, reserved, settled and paid values remain separately sourced, timed and currency-qualified.", "Authority hold: claimant assertion, observed fact, expert opinion, insurer position, settlement and regulator or court decision do not prove one another.", "Identity hold: duplicate, related, parent-child, successor, multi-policy and multi-insurer relations require explicit evidence and must preserve predecessors.", "Privacy hold: personal, health, financial, location, evidence, fraud and legal data require purpose limitation, minimization, access controls and auditable disclosure.", "Source-access hold: ACORD licensed artifacts were not accessed; only official public overview material was used, and no ACORD conformance is claimed.", "Maturity hold: HL7 FHIR R5 Claim-family resources are Trial Use and health-specific, not a universal claim model.", "Interoperability hold: every FHIR, ACORD, code-list, temporal, provenance, quality and policy projection needs exact release pins, conformance evidence and loss declarations.", "Review hold: insurance, claims, actuarial, legal, privacy, security, records and independent external review are outstanding.", "Independent external review was explicitly waived by the repository owner; this codex-only result remains a reviewable draft." ], "deferredResearch": [ "Approve or reject the WM-ECO-003 and WM-ACT-045 candidate relations and define claim-to-policy, claim-to-handling-case, multi-insurer, reopening, split and merge cardinality.", "Create independently validated life, health, disability, workers compensation, property, motor, liability, travel, cyber, marine, reinsurance, catastrophe and public-scheme profiles.", "Benchmark claim identity matching, claim-line codes, evidence requirements, amount classes, coordination of benefits, duplicate detection, privacy, retention and cross-border handling.", "Validate jurisdiction, policy class, claimant standing, limitation, coverage, liability, settlement, payment, appeal, complaint, fraud and regulator rules.", "Pin exact external releases and licensing conditions and obtain independent insurance, claims, legal, privacy, security and records review before promotion beyond reviewable-draft assurance." ] }, "statistics": { "sources": 24, "bundles": 6, "layers": 12, "findings": 24, "questions": 72, "artifacts": 24, "functions": 10 } }