How we got here, in one sentence

• Briefly describe the reconciliation outcome for your organization that triggered this conversation.
• How many dollars below projection was your first full reconciliation year? Options: <$1M, $1M–$3M, $3M–$5M, $5M–$10M, >$10M
• Name the role on your team that first raised the concern about rising-risk members. Options: VP of Population Health, Chief Medical Officer, Director of Care Management, Chief Financial Officer, Other
• Walk me through the last time a reconciliation surprise forced urgent action at your organization, what happened and who scrambled to respond?
• Which time window is your leadership watching to avoid moving from shared savings into shared losses? Options: Next 3 months, 3–6 months, 6–12 months, Beyond 12 months

Where the forecast is actually breaking

• How would missing 10% of rising-risk members change your reconciliation outcome next year for your organization?
• Which member cohorts in your population produced the biggest unanticipated costs last year? Options: High-risk chronic conditions (diabetes, CHF), Behavioral health with comorbidity, Polypharmacy/complex meds, Recently discharged patients, High ED users, Other
• Approximately how many avoidable ED visits and admissions were flagged retrospectively in your data last year?
• What single operational failure in your current process made those cases slip through?
• If you could guarantee one outcome from a pilot for your organization, which metric would make you sign immediately? Options: Avoidable admissions reduction, Avoidable ED visits reduction, Reconciliation variance dollars, Rising-risk detection rate, Care manager workflow adoption, Other

How your team actually finds and reaches rising-risk members

• Why does your current process miss members who later become high-cost, from your point of view?
• Describe the tools and reports your care managers use today to prioritize outreach.
• List the specific reports or dashboards that routinely drive your team's weekly care manager huddles.
• Identify your typical approval path and timeline for changing care management workflows in your organization.
• Estimate the percentage of outreach tasks in your operation that require duplicate data entry across platforms. Options: 0–10%, 10–25%, 25–50%, 50–75%, 75–100%

Data readiness, ownership, and the hard integration facts

• What single data gap in your systems would stop us from running a valid 12-month retrospective pilot?
• Which of these feeds does your organization have available today, select all that apply? Options: Adjudicated claims, Encounter data, EHR clinical notes, Lab results, Pharmacy claims, SDOH/social needs data, Other
• Do APIs or SFTP exports exist for your feeds, and which of these describes your current extract method? Options: APIs, SFTP/batch exports, Both APIs and SFTP, Manual extracts only, Not available
• Name the team or role in your organization that owns those feeds and is authorized to provide access.
• Estimate your member matching failure rate for those feeds, percent of records that fail deterministic or probabilistic matching. Options: <1%, 1–3%, 3–7%, 7–15%, >15%
• Are there legal approvals, data use agreements, or privacy reviews in your organization that typically add more than four weeks to onboarding? Options: Yes, No, Unsure
• If we require delivery of 12 months of claims and clinical data within six weeks, which internal barrier in your organization would prevent that?

Can the platform fit inside your care team's daily workflow?

• What would need to be true for your care managers to prefer this platform over their current EHR tools?
• Which EHR or care management system categories must we integrate with for your pilot, select all that apply? Options: Enterprise health system EHR, Community provider EHRs, Third-party care management platform, Health information exchange, Proprietary spreadsheets/processes, Other
• Name the person or role on your team authorized to provision integration accounts and run endpoint tests.
• How many care managers from your organization will be in scope for the pilot and what are their average daily caseloads?
• What acceptance test would prove the workflow integration meets your care managers' needs? Options: Task creation in EHR with member context, Single sign-on and access control, Bi-directional status updates, No duplicate data entry, Time-to-first-outreach under 48 hours, Other

What's realistically competing for this budget and attention

• If you kept your current analytics and augmented staff instead of buying a platform, what would have to change in your organization to keep you from switching?
• Which external options is your organization actively evaluating, pick all that apply? Options: Incumbent vendor refresh, New platform, Point analytics vendor, Internal build, Consulting services, Not evaluating external options
• What aspects of your incumbent vendor or an internal build make it appealing to your team?
• Which leaders on your team are advocating for an internal build or staying with the incumbent, and what are their main concerns?
• Is there an internal proposal in your organization to solve this without an outside vendor, and if so which team proposed it? Options: Yes, No, Unsure

The proof points and acceptance criteria that would close this fast

• If a pilot delivered a 20% reduction in avoidable admissions for your population, which internal approvals would accelerate immediate scale?
• Which specific metrics will your organization use to judge pilot success, pick up to five? Options: Avoidable admissions reduced, Avoidable ED visits reduced, Reconciliation variance dollars, Rising-risk true positive rate, Care manager task completion rate, Time to first outreach, Member engagement rate
• What minimum improvement in those metrics for your pilot would lead you to proceed to a commercial commitment?
• Identify the signatories required for pilot acceptance in your organization and their typical decision timelines.
• If the pilot meets targets, which procurement or contracting steps in your organization are most likely to delay a commitment? Options: Legal review, Security review, Data use agreement negotiation, Budget approval, Vendor contracting, Other

Risks, unknowns, and the one thing that stops us

• List the one risk in your organization that would stop this project the day before data transfer.
• Which internal resources can your organization commit to the pilot, select all that apply? Options: Project manager (buyer side), Data engineer/ETL resource, Care manager champions, IT/security reviewer, Clinical informaticist, Legal or contracting contact, No internal resources available
• Which target date would your team like to start the pilot? Options: Within 2 weeks, Within 4–6 weeks, Within 6–12 weeks, Next quarter or later
• Who will act as the day-to-day project lead on your side, name role or person?
• If our team removes one blocker this week, what fast decision from your team would move contract signing into this month?

• Solution Experience: Catch Rising-Risk Members Earlier

• Confirm the current state and its cost
• You confirm the demonstrated detection would have flagged the known high-cost members from last year's reconciliation.
• Run a risk-score comparison using the buyer's provided 12 months of claims and clinical data and deliver a gap analysis before the follow-up session.
• You confirm the generated care manager task fits into your existing EHR workflow and removes the need for duplicate data entry by care managers.
• Show how multi-source data builds a longitudinal member profile
• Provide a de-identified 12-month extract of claims and clinical records for the pilot population and identify five known high-cost members for validation.
• You agree the projected reduction in avoidable ED visits and admissions aligns with the financial consequence required to close the $3,000,000 gap.
• Demonstrate rising-risk detection on a 12-month sample
• Identify the primary EHR integration endpoint and the named owner of the care management workflow for integration testing.
• Validate EHR workflow integration and task handoff
• Prepare a draft projected impact summary that maps avoided ED visits and admissions to reconciliation dollars for the buyer's sample.
• Confirm this matches what you meant

• Solution Experience: Catch Rising-Risk Members Earlier
• Solution Experience Deck
• Solution Brief

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• Load and Normalize 12‑Month Claims Dataset
• Integrate Clinical EHR Data Feed
• Ingest Pharmacy, Lab, and SDOH Data
• Member Identity Resolution and Longitudinal Profile Build
• Risk‑Score Calibration to Local Population
• Deploy Rising‑Risk Detection and Stratification
• Configure Care Gap Logic for Quality Measures
• Embed Care Manager Task and Outreach Workflows
• EHR Workflow Integration and Task Synchronization
• Pilot Cohort Launch with Outreach Automation
• Train Care Management Staff on Platform Workflows
• Enable Outcomes and Cost Tracking Dashboards
• Data Quality Monitoring and Remediation

Load and Normalize 12‑Month Claims Dataset

• Do you have a contiguous 12-month set of adjudicated medical and pharmacy claims (payer adjudication files) for the pilot population? Options: Yes, No, Partial
• What format are your claims exports delivered in? Options: EDI X12 837 / 835, CSV / pipe-delimited flat files, Database dump (SQL) or parquet, Other
• How many unique members are included in the twelve-month claims extract you will provide for the pilot? Options: <5,000, 5,000-50,000, 50,000-200,000, >200,000, Unknown
• Select the payer-level identifier fields present on your claims files that we should use for joins (payer ID, BIN/PCN, plan code, contract number). Options: Payer ID, BIN/PCN, Plan code, Contract number, Other
• Confirm whether admitting diagnosis, place-of-service, and admission/discharge dates are populated so we can flag ED visits versus inpatient stays. Options: All present, Partially present, Not present
• What acceptance criteria will confirm claims loading is complete (for example record counts match your monthly adjudication summary or per-file totals)?

Integrate Clinical EHR Data Feed

• Do you have an HL7 ADT feed, CCD/CCDA files, or a FHIR API available from your EHR for the pilot cohort? Options: HL7 ADT, CCD/CCDA via SFTP, FHIR API (Patient/Encounter), None available
• Select which EHR endpoint types you can provision for the pilot (for example SMART on FHIR, bulk FHIR export, direct SFTP CCD). Options: SMART on FHIR, Bulk FHIR export, CCD/CCDA via SFTP, Direct API / vendor connector, Other
• How will you prefer patient matching between EHR and claims to be performed (authoritative member ID, MRN plus DOB, deterministic, probabilistic matching)? Options: Authoritative member ID, MRN + DOB + name, Deterministic (exact), Probabilistic (fuzzy)
• Indicate which clinical domains you need from the EHR for stratification and workflows (problem list, medication list, allergy, labs with LOINC, vitals, encounter notes). Options: Problem list, Medications, Allergies, Labs (LOINC), Vitals, Encounter notes, Other
• Who is the technical owner for the EHR feed on your side (name, role, contact) so we can coordinate connector setup?
• Provide any security, certificate, or network requirements for the EHR integration endpoint (IP whitelist, mutual TLS, OAuth scopes).

Ingest Pharmacy, Lab, and SDOH Data

• Identify the pharmacy data sources you will supply for the pilot (PBM adjudicated claims, e-prescribing logs, dispense history, NCPDP). Options: PBM adjudicated claims, E-prescribing feed, Dispense history, NCPDP, None
• Are your lab feeds delivered with LOINC codes and numeric result fields for key tests (for example HbA1c, BMP, BNP)? Options: Yes, LOINC + numeric, LOINC but not numeric, Lab names only, No lab feed
• How frequently do you expect pharmacy, lab, and SDOH sources to be ingested for the pilot (daily, weekly, monthly)? Options: Daily, Weekly, Monthly, Other
• List how SDOH data is captured in your workflows (screening tool name, enrollment form fields, vendor feed) and which SDOH domains are required (housing, food insecurity, transportation).
• Do you require field-level mappings such as NDC to RxNorm or lab LOINC normalization as part of ingestion? Options: Yes, No, Partial
• Specify any lab or pharmacy mapping accuracy threshold you expect before records are considered usable (for example >95% mapping rate).

Member Identity Resolution and Longitudinal Profile Build

• Indicate the unique identifiers you consider authoritative for member linking (payer member ID, subscriber ID, MRN, SSN where permitted). Options: Payer member ID, Subscriber ID, MRN, SSN (if permitted), Other
• How should conflicting demographic records be resolved during profile build (prefer most recent, prefer payer source, manual reconciliation)? Options: Prefer most recent, Prefer payer source, Manual reconciliation required
• Confirm whether you will provide an attribution roster (list of attributed members) to seed longitudinal profiles for the pilot. Options: Yes, file will be provided, No, use claims-based attribution only, Partial roster
• Choose the maximum acceptable false-match rate for member linking (for example <=1%, <=2%, <=5%) to guide matching thresholds. Options: <=1%, <=2%, <=5%, No threshold specified
• Who will approve and sign off on the resolved master member mapping file on your side (name and role)?
• Where should the master member resolution file be stored and who should have access (SFTP location, cloud bucket, secure API)? Options: SFTP, Secure cloud bucket, Secure API, Other

Risk‑Score Calibration to Local Population

• Identify the primary historical outcome you want the risk model calibrated against for the pilot (avoidable ED visits, unplanned admissions, total cost per member). Options: Avoidable ED visits, Unplanned admissions, Total cost per member, Other
• When should the calibration window end and how many months back should be included (for example last 12 months ending MM/YYYY)? Options: 12 months, 24 months, Other
• Specify any local diagnosis or procedure codes we should upweight or treat specially during calibration (provide ICD-10 or CPT examples).
• How many labeled outcome events do you have for calibration and validation (count of members with documented avoidable ED visits or unplanned admissions)? Options: <100, 100-499, 500-2,499, >=2,500, Unknown
• What acceptance criteria will confirm model calibration success (for example target sensitivity, PPV, AUC improvement, or operating point for avoidable admissions)?
• Who on your clinical team will provide clinical sign-off for final risk thresholds and calibration artifacts?

Deploy Rising‑Risk Detection and Stratification

• Which rising-risk detection approaches should we enable by default for the pilot (utilization slope, event-based triggers, gap accumulation, medication adherence flags)? Options: Utilization slope, Event triggers, Gap accumulation, Medication adherence
• How many days of lead time do you require between risk detection and expected outreach (for example 14 days, 30 days)? Options: 14 days, 30 days, 60 days, Other
• How many discrete risk bands should be surfaced to care managers (for example 3 bands: high/medium/low; or 4 bands including rising)? Options: 2 bands, 3 bands, 4 bands, Custom
• How should the platform present top contributing drivers for each flagged member (top diagnoses, missed meds, recent ED visit, gaps in care)? Options: Top diagnoses, Medication gaps, Recent utilization, Composite reason list
• Are there any consent, program, or regulatory constraints that prevent flagging or outreach to specific member groups (for example minors, behavioral health carve-outs)? Options: Yes, No, Conditional
• Where should rising-risk alerts be routed operationally (care manager platform inbox, EHR task, secure message, email)? Options: Platform inbox, EHR task, Secure message, Email

Configure Care Gap Logic for Quality Measures

• Which specific quality measures must have gap logic configured for the pilot (list HEDIS measure IDs, NCQA or CMS star measures by name/ID)?
• Upload or provide a link to your prioritized top 5 measures and any internal spec documents we should align to.
• Confirm whether you have existing measure definitions or logic libraries we should reuse (for example HEDIS spec, internal measure spec). Options: Yes, HEDIS spec, Yes, internal spec, No
• State how often measure gap status should be recalculated for pilot operations (daily, weekly, monthly). Options: Daily, Weekly, Monthly, Other
• What acceptance criteria will confirm measure logic accuracy during pilot validation (for example sample audit of 100 members with >=98% concordance with internal chart review)?
• Who on your quality or clinical team will own measure audits and final sign-off (name and role)?

Embed Care Manager Task and Outreach Workflows

• Describe the care manager roles that will consume generated tasks (registered nurse care managers, social workers, community health workers).
• State the required task fields that must appear when a care manager receives a task (member contact phone, last encounter date, principal risk drivers, suggested outreach script).
• Specify whether you require condition-specific outreach scripts (for example diabetes, COPD, heart failure) and if we should adapt them to your local language and tone. Options: Yes, provide scripts, No, we will provide scripts, Partial
• Outline escalation rules you want enforced by the workflow (for example escalate to supervisor after 3 failed outreach attempts or 7 days without contact).
• Indicate whether outbound outreach must be written back to the EHR as an encounter/note, stored in the platform only, or both. Options: EHR encounter, Platform only, Both
• How many care manager seats will need role-specific training and access during the pilot? Options: 1-5, 6-20, 21-50, 50+

EHR Workflow Integration and Task Synchronization

• Which EHR integration mechanisms will you accept for task synchronization (SMART on FHIR, EHR task API, HL7 message, proprietary connector)? Options: SMART on FHIR, EHR task API, HL7 message, Proprietary connector, Other
• Do you require bi-directional synchronization so task status updates flow from the EHR back to the platform? Options: Yes, No, Only one-way to EHR
• Name the EHR fields that must be populated when a task is created (encounter ID, provider NPI, note text) and any character limits we must respect.
• Confirm technical prerequisites for the EHR connector such as IP allowlist entries, network peering, or certificate exchange. Options: IP allowlist required, Network peering required, Certificate exchange required, No special prerequisites
• Who is the EHR technical owner and what is their typical SLA for processing connector requests (number of days to respond/approve)?
• Specify a practical validation sample for task synchronization (for example 100 tasks or 30 days of activity) that would demonstrate operational readiness. Options: 30 days, 100 tasks, Other

Pilot Cohort Launch with Outreach Automation

• Define the inclusion criteria for the pilot cohort (attribution roster, risk band threshold, condition-specific cohort identifiers).
• How many members do you plan to include in the pilot cohort? Options: <500, 500-2,500, 2,500-10,000, >10,000
• Which automated outreach channels are you willing to permit for pilot communications (phone, SMS, secure portal message, email)? Options: Phone, SMS, Secure portal, Email
• Explain the consent or opt-out process that must be followed before automated outreach (documented consent, verbal consent on file, state-specific rules).
• Identify the baseline period and metric you will use to compute pilot reductions in avoidable ED visits or admissions (for example prior 12 months claims adjudicated ED counts).
• Describe the staffing and daily capacity you will commit to pilot outreach (FTEs, average calls per day, hours available).

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• Master Services Agreement (MSA)
• Statement of Work (SOW) — Pilot & Implementation
• Subscription Order Form / Subscription Agreement
• Data Access and Use Agreement
• Acceptance Criteria & Pilot Completion Annex
• HIPAA Business Associate Addendum (BAA)
• Service Level Agreement (SLA) Attachment
• Project Roles & Responsibilities Attachment (RACI)
• Change Order Agreement

• Go-live Health Check (weeks 1-4)
• First Outcome Measurement (weeks 4-10)
• Acceptance Gate Review (around day 90)
• Quarterly Success Review (ongoing)

• Schedule the next quarterly review and circulate pre-read analytics seven days prior.
• Run a targeted validation of rising-risk recall using the identified high-cost cohort and publish the results.
• Adjust task routing or outreach script and document expected impact on time-to-first-outreach.
• Restate acceptance criteria and numeric targets
• Produce a documented pass or fail per acceptance criterion recorded in the Risk Stratification Evaluation stage.
• Capture the named signatory and date for the formal acceptance decision.
• Document remediation actions and timelines for any conditional or failed items required to reach acceptance.
• Publish the acceptance record with pass/fail per criterion and the named signatory.
• If conditional or failed, create a remediation tracker with tasks, owners, and target completion dates.
• Schedule a short follow-up checkpoint to confirm remediation progress before final acceptance is re-evaluated, if required.
• Performance review against core outcomes
• Confirm that avoidable ED visits per 1,000 members and reconciliation shortfall in dollars are on a sustainable trajectory or have owned remediation plans.
• Ensure persistent blockers have owners and realistic resolution dates and that enhancement requests are prioritized for the next quarter.
• Verify that model calibration cadence and integration uptime meet the operational expectations agreed during deployment.
• Publish the quarterly performance dashboard with the reconciliation and avoidable ED visit trend lines for shared review.
• Move agreed enhancement requests into a scoped change list with target delivery quarters.
• Re-confirm success criteria and owners
• All critical ingestion pipelines and integration endpoints report healthy or have documented remediation plans.
• Incumbent system decommission status documented and archival or read-only decision recorded.
• Named owners and target dates recorded for all high-priority open issues.
• Publish a deployment health checklist with pipeline status and open defects for async tracking.
• Archive or mark incumbent system as read-only and publish the data migration completion record.
• Run a targeted data quality fix for any feed blocking rising-risk identification and report completion date.
• Present first outcome data vs targets
• Confirm whether avoidable ED visits rate and avoidable inpatient admissions rate are moving toward the targets recorded in the Risk Stratification Evaluation stage.
• Document root causes for any metric shortfall and commit to corrective actions with deadlines.
• Confirm timeline to the acceptance gate and list the outstanding items required for the acceptance decision.
• Deliver a remediation plan that lists data fixes, model recalibration steps, and workflow training tasks with due dates.
• Present outcome data against each acceptance criterion
• Persistent issues and blocker burn-down
• Deployment and data feed validation
• Validate rising-risk identification accuracy
• Document pass, fail, or conditional results
• Early adoption and usage signals
• Enhancement and change requests channel
• Care management workflow integration check
• Operational health and model drift check
• Capture formal acceptance decision
• Incumbent system wind-down
• Root-cause analysis for gaps
• Agree corrective actions and timeline to acceptance gate
• Agree remediation plan for any failed criteria
• Short action alignment and next steps
• Open issues and immediate remediation