DEMO MODE

Governance & Audit

Operational governance controls. Human-reviewed dispositions.

Framework v2.4.0Last policy review: May 2026

Workflow Lifecycle

  1. Stage 1

    Rule-Based Processing

    Intake

    Claims enter via state data adapter. Domain classification: pharmacy, transportation, provider, institutional, behavioral health. Classification only. Final disposition requires analyst review.

  2. Stage 2

    Rule-Based Processing

    Risk Prioritization

    Rule library evaluates configurable thresholds. Operational risk classification 0–100. No automated disposition at this stage. Classification only. Final disposition requires analyst review.

  3. Stage 3

    Human Review Required

    Analyst Review Queue

    Claims above state threshold enter analyst queue. Human review required before prepayment escalation.

  4. Stage 4

    Analyst Decision

    Disposition

    Analyst disposition: Return to Adjudication, Documentation Review, Supervisor Escalation, or Program Integrity Review Package Preparation.

  5. Stage 5

    Supervisor Signoff Required

    Supervisor Review

    Escalated items require supervisor signoff. Overrides require documented justification.

  6. Stage 6

    System Logged

    Audit Log

    All analyst and supervisor actions logged: timestamp, user ID, disposition, justification. Append-only export.

Operational Friction · Workload Conditions

Active Backlog

247

Cases awaiting analyst pickup

Aging > SLA

38

Cases past first-touch SLA

Awaiting Documentation

61

Provider response pending

Escalated · Supervisor Review

14

Routed for supervisory disposition

Threshold Override Submitted

5

Pending governance committee review

Secondary Review Required

9

Routed to peer analyst

Review Loopbacks (7d)

12

Returned for additional documentation

Disposition Reversals (30d)

3

Supervisor-rescinded determinations

Incomplete Provider Responses

27

Partial documentation submitted

Pending Justification

11

Analyst rationale required before signoff

Duplicate Escalations Detected

4

Cross-pod routing collisions (7d)

Audit Follow-Up Queue

19

Items pending State Audit closure

Governance Exceptions (Open)

7

Policy deviations awaiting committee review

Escalation Bottleneck Index

1.8 ×

Supervisor queue depth vs. 30d baseline

Supervisor Review Delay (Median)

2.4d

Time from escalation to disposition

Workload Surge (24h)

+22%

Intake above rolling 14d mean

Workload Distribution Variance · Analyst Pods

Capacity vs. authorized staffing baseline
Pod ANortheast
Balanced
Active 62 · Aging 784%
Pod BMid-Atlantic
Surge
Active 91 · Aging 14118%
Pod CSoutheast
Balanced
Active 47 · Aging 471%
Pod DMidwest
Elevated
Active 78 · Aging 11104%
Pod EMountain / Plains
Balanced
Active 33 · Aging 258%
Pod FPacific
Constrained
Active 84 · Aging 9126%

Disposition Cycle Variance · By Review Domain

Rolling 14d · vs. quarterly baseline
Disposition cycle variance by review domain
DomainMedian CycleP90 CycleVarianceState
Pharmacy1.6d4.2d+18%Elevated
Transportation2.1d5.8d+34%Delayed
Behavioral Health2.7d7.1d+41%Delayed
Institutional1.2d3.4d+6%Within Target
Provider Network1.4d3.9d+11%Within Target
Cross Domain Patterns3.1d8.4d+52%Delayed

Cycle variance reflects staggered review states, documentation dependencies, supervisor review delays, and governance committee scheduling. Variance is expected in enterprise oversight environments and is monitored, not eliminated, by program integrity leadership.

Recent Workflow Conditions

Rolling 4h window
  1. 11:48·ALT-0214
    Disposition Under Review

    Supervisor L. Hernandez requested additional source documentation before sign-off.

  2. 11:32·ALT-0207
    Awaiting Documentation

    Provider response pending. Second outreach scheduled per provider-engagement protocol.

  3. 11:14·ALT-0198
    Threshold Override Submitted

    Analyst override of pharmacy risk threshold submitted for governance committee review.

  4. 10:57·ALT-0186
    Secondary Analyst Review Required

    Cross domain billing pattern routed to peer analyst per dual control policy.

  5. 10:41·ALT-0172
    Documentation Validation In Progress

    Source records under review by program integrity documentation specialist.

  6. 10:18·ALT-0159
    Audit Escalation Triggered

    Case routed to State Audit oversight per repeat-finding escalation rule.

  7. 09:52·ALT-0141
    Governance Review Pending

    Disposition held for monthly governance review · scheduled committee cycle.

  8. 09:33·ALT-0128
    Escalated · Pending Supervisor Review

    P1 disposition routed for supervisory approval before payment-disposition finalization.

  9. 09:11·ALT-0117
    Duplicate Escalation Detected

    Case previously routed by Pod-B identified during Pod-D intake; consolidated under originating analyst.

  10. 08:54·ALT-0103
    Pending Justification

    Analyst rationale required before threshold-override request advances to governance committee.

  11. 08:37·ALT-0091
    Audit Follow-Up Open

    State Audit requested supplemental disposition notes prior to finding closure.

  12. 08:12·ALT-0078
    Governance Exception Filed

    Policy deviation logged for pharmacy-domain threshold; queued for monthly governance committee review.

Workflow states reflect realistic operational conditions in state program integrity environments, including review loopbacks, documentation dependencies, supervisor intervention, and audit-oversight escalation. All payment actions require documented analyst review and supervisory disposition where required.

False Positive Rate Governance

Current False Positive Rate
4.2%
Target Threshold
< 5%
Analyst Override Rate
18.3%
Override rates tracked by rule and domain. High false positive rules flagged for recalibration.

Rule Threshold Review Schedule

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Governance Commitments

Explainability

Risk scores include rule firings and threshold context.

Human Oversight

No prepayment escalation without analyst disposition.

Auditability

Full audit trail for scoring, analyst action, and threshold changes.

Fairness Validation

Rule performance monitored for disparate impact across beneficiary categories.

Threshold Transparency

Detection thresholds configurable, documented, and governance-reviewed.

State Sovereignty

States control thresholds, rule activation, and review routing. Framework produces signals only.