← Methodology

Artifact Taxonomy

A registry of administrative artifact classes that look like protected processes and function as discretionary intake. Each entry holds the written question that collapses the ambiguity, the custody the carrier must acknowledge, the regulatory anchor that grounds the protected-process framing, and the branch logic for both possible replies.

This page is the outer taxonomy. The within-class classification — for the denial branch, that is the engine’s pattern_id and issue_family system — operates one level inside each entry. New artifact classes are added here as one entry under the same schema, not as parallel doctrine branches.

Artifact class · denial

Insurance Coverage Denial

What it looks like to the member

A denial letter, portal message, EOB line, or phone notification stating that a service or claim is not covered, not authorized, or not paid.

What it pretends to be

A formal coverage determination subject to internal appeal rights, external review rights, and statutory timelines.

What it actually is

An administrative output that may or may not have been entered as an Adverse Benefit Determination subject to those rights — depending on whether the member received a written notice satisfying the regulatory definition, and whether the carrier has assigned the matter to its appeals queue with a named decision deadline.

Written question

Please confirm in writing whether the [denial / coverage decision communicated on (date)] has been entered as a formal Adverse Benefit Determination subject to internal appeal rights — with a reference number, the appeal-filing deadline, the carrier's appeal-decision deadline, and the obligation to issue a written determination — or state that no formal Adverse Benefit Determination has been issued and what the [denial / coverage decision] therefore is for purposes of any subsequent review.

Custody the carrier must acknowledge

  • Adverse Benefit Determination case reference number
  • Appeal-filing deadline date
  • Carrier's appeal-decision deadline date
  • Written-determination requirement explicitly acknowledged
  • Identification of the reviewer or reviewing body

Regulatory anchors

Florida

Fla. Stat. § 627.6043; Fla. Admin. Code 69O-191.046

Adverse benefit determination; internal grievance; written notice

Federal/ERISA

29 C.F.R. § 2560.503-1

Adverse benefit determination; full and fair review; written decision in 60 days (post-service) / 30 days (pre-service)

Federal/ACA

45 C.F.R. § 147.136

Internal claims and appeals; external review process

Branch logic

If carrier confirms opened

Trigger. Carrier confirms an Adverse Benefit Determination has been issued, with a case reference, appeal-filing deadline, and decision deadline.

Next move. File the internal appeal within the deadline using the proof package the carrier is now obligated to consider; preserve the written confirmation as the audit-trail anchor.

Documentation. ABD reference number; carrier's stated decision deadline; the written confirmation email or letter.

If carrier does not confirm opened

Trigger. Carrier states no ABD has been issued, or refuses to confirm in writing.

Next move. Issue a written demand that the carrier produce the ABD with the regulatory citation. The refusal to confirm or to issue is itself the actionable artifact.

Documentation. The carrier's refusal-to-confirm communication; the dated written demand for an ABD; the carrier's response or silence.

Escalation lane (not-opened branch)

Florida DFS complaint citing Fla. Stat. § 626.9541(1)(i) (unfair claim settlement practices) and the carrier's failure to issue a written ABD.

Scope

Florida PPO, fully-insured commercial only. The diagnostic frame and forcing question apply to ERISA self-funded plans as well, but the citation stack and escalation lane differ; ERISA cases route through 29 C.F.R. § 2560.503-1 internal claims procedures and DOL EBSA enforcement rather than Florida DFS. A scope-narrowed ERISA entry can be added when needed.

Most-developed artifact class in the engine. The FL PPO denial classifier (engine/classifier_v2.py + engine/pattern_library.json) produces the within-class pattern_id and issue_family that drive paid_eligible routing. This entry is the OUTER taxonomy — the patterns and issue families live one level inside it.

Artifact class · continuity-of-care

Continuity of Care Request

What it looks like to the member

A request submitted to the carrier — typically after a network change, a provider termination, or a new enrollment — for permission to continue seeing an out-of-network provider at in-network cost-sharing for a transition period, citing an in-progress course of treatment.

What it pretends to be

A regulated transition-of-care process with a defined review track, decision deadline, and written determination — analogous to a coverage exception or appeal.

What it actually is

An administrative intake that often functions as a discretionary courtesy review at the carrier's pace, with no enforceable confirmation that the request has been logged as a reviewable case unless the member explicitly forces it.

Written question

Please confirm in writing whether my continuity-of-care request submitted on (date) for (provider) covering (condition / course of treatment) has been opened as a formal continuity-of-care review — with a reference number, the named clinical or administrative reviewer, the review-decision deadline, and the obligation to issue a written determination — or state that no formal review has been opened and what administrative track this submission is currently in.

Custody the carrier must acknowledge

  • Continuity-of-care case reference number
  • Named reviewer or reviewing body
  • Review-decision deadline date
  • Written-determination requirement explicitly acknowledged
  • Stated administrative track of the submission if not opened as a formal review

Regulatory anchors

Florida

Fla. Stat. § 641.51(8) (HMO continuity of care for terminating providers); Fla. Stat. § 627.6471(6) (PPO transitional coverage on provider termination)

Continuing care provisions; ongoing course of treatment; member entitlement to continuation

Federal/ACA

45 C.F.R. § 156.230(d) (continuity of care for QHPs when a provider leaves the network mid-treatment)

Treatment for a serious and complex condition; treatment that requires continuity

Federal/NSA

Public Health Service Act § 2799A-3; 26 U.S.C. § 9818

Continuing care patient; transitional 90-day continuation at in-network cost-sharing

Branch logic

If carrier confirms opened

Trigger. Carrier confirms the request is opened as a formal continuity-of-care review with reference, reviewer, and decision deadline.

Next move. Submit the clinical documentation that grounds the continuing-care criteria within the review window; track the deadline; preserve the written confirmation.

Documentation. CoC review reference number; assigned reviewer; carrier-stated decision deadline; the written confirmation.

If carrier does not confirm opened

Trigger. Carrier states no formal review has been opened, or describes the submission as a 'general inquiry,' 'courtesy review,' 'transitional consideration,' or refuses to confirm administrative track.

Next move. Issue a written demand that the carrier open a formal continuity-of-care review citing the applicable state and federal continuity-of-care framework. The non-opening is itself the actionable artifact.

Documentation. The carrier's non-opening communication or refusal-to-confirm; the dated written demand; the carrier's response or silence.

Escalation lane (not-opened branch)

Florida DFS / Florida Office of Insurance Regulation complaint citing the applicable continuity-of-care statute and the carrier's refusal to open a reviewable track; concurrent CMS / NSA enforcement complaint if the No Surprises Act continuing-care provision applies.

Scope

Florida PPO and HMO; federal continuity provisions apply across plan types where the trigger condition (provider termination, network change, ongoing course of treatment) is present. Self-funded ERISA plans share the diagnostic frame but route through different regulatory anchors.

First entry added under this taxonomy after the engine's denial branch. Validates the pattern: each artifact class is one entry under one schema, not a parallel branch.

Artifact class · prior-authorization

Prior Authorization Request

What it looks like to the member

A request the member, prescriber, or facility submits to the carrier — by portal, fax, or phone — asking the carrier to authorize a service, procedure, or prescription before it is delivered, with the carrier returning some combination of approved, denied, pending, additional-information-required, or simply silence past the expected response window.

What it pretends to be

A regulated utilization-review determination subject to statutory response timelines, written-decision requirements, and pre-service appeal rights when denied.

What it actually is

An administrative intake that may or may not have been opened as a formal utilization-review determination subject to those rights — depending on whether the carrier has assigned a case reference, named a reviewer, committed to a decision deadline, and acknowledged the obligation to issue a written approval or denial. 'Pending,' 'in process,' and 'additional information required' are not, by themselves, formal determinations.

Written question

Please confirm in writing whether my prior authorization request for [service / medication / procedure] submitted on (date) for (member) has been opened as a formal utilization-review determination — with a reference number, the named clinical or administrative reviewer, the decision deadline applicable to this request (urgent vs. non-urgent), and the obligation to issue a written approval or denial — or state that no formal determination has been opened and what administrative track this submission is currently in.

Custody the carrier must acknowledge

  • Prior authorization case reference number
  • Named clinical or administrative reviewer
  • Decision deadline applicable to this request (urgent vs. non-urgent)
  • Written-determination requirement explicitly acknowledged
  • Stated administrative track of the submission if not opened as a formal determination

Regulatory anchors

Florida

Fla. Stat. § 627.42392 (prescription drug prior authorization — timelines, written notice, denial procedures); Fla. Stat. § 627.6471 (PPO coverage framework, including utilization review and precertification)

Prior authorization; utilization review; written notice of denial; reasonable decision timeframe

Federal/ERISA

29 C.F.R. § 2560.503-1(f)(2)(i) (urgent care claims — 72 hours); 29 C.F.R. § 2560.503-1(f)(2)(iii) (pre-service claims — 15 days)

Urgent care claim; pre-service claim; full and fair review; written decision within prescribed timeframe

Federal/ACA

45 C.F.R. § 147.136 (internal claims and appeals for pre-service claims, including prior auth)

Pre-service claim handling; internal appeal of adverse determination

Branch logic

If carrier confirms opened

Trigger. Carrier confirms the prior authorization is opened as a formal utilization-review determination with reference, reviewer, and decision deadline.

Next move. Submit the clinical documentation supporting medical necessity within the review window; track the deadline; preserve the written confirmation. If denied, the written denial unlocks the pre-service appeal track.

Documentation. Prior auth case reference number; assigned reviewer; carrier-stated decision deadline; the written confirmation.

If carrier does not confirm opened

Trigger. Carrier states no formal determination has been opened, describes the submission as 'pending,' 'in process,' or 'awaiting clinical review' past the applicable timeframe, or refuses to confirm administrative track.

Next move. Issue a written demand that the carrier either issue a formal utilization-review determination within the applicable statutory or regulatory timeframe, or acknowledge in writing that the request has not been opened as a determination. Silence past the timeframe is itself the actionable artifact — most state and federal frameworks treat it as a constructive denial that triggers pre-service appeal rights.

Documentation. The carrier's non-opening communication or silence; the dated written demand; the carrier's response; the submission timestamp that establishes the elapsed window.

Escalation lane (not-opened branch)

Florida DFS / Florida Office of Insurance Regulation complaint citing the applicable prior-authorization statute and the carrier's failure to issue a formal determination within the required timeframe; for ERISA self-funded plans, DOL EBSA complaint citing 29 C.F.R. § 2560.503-1 timeliness violations and the constructive-denial doctrine.

Scope

Florida PPO, fully-insured commercial. The diagnostic frame and forcing question apply across plan types, but the citation stack and escalation lane differ for ERISA self-funded plans (DOL EBSA route via 29 C.F.R. § 2560.503-1 timeliness requirements) and for Medicare Advantage / Medicaid managed care (CMS route, separate regulatory framework). A scope-narrowed entry can be added for those branches when needed.

Third entry in the registry. The engine's denial classifier currently routes prior-authorization denials through the denial pattern_id and issue_family system once a written denial is issued — this entry covers the upstream artifact (the request itself and the carrier's acknowledgment or non-acknowledgment of it as a formal determination), which the engine does not currently classify because there is no denial text to classify until the carrier acts.

Not legal advice. Florida-PPO scope unless an entry notes otherwise.

Three pillars · classification, coordination, record-building · how coordination works → · administrative record-building, not legal action.