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A multi-site clinic’s assistant drafts visit notes, handles refill requests, answers portal messages, and assembles prior authorization packets. A check outside the assistant sends drafted notes to the treating clinician for signature, holds changes to treatment for a named, licensed person, refers disclosures outside treatment, payment, and health care operations to the privacy office, and lets routine tasks such as scheduling through.
Illustrative case. The clinic is fictional and the page is not clinical guidance, but the federal and state rules cited are real. Bracketed values are settings each organization chooses with its clinical and compliance leads.
The assistant listens to visits (with consent) and drafts notes, triages refill requests, answers portal messages, sends records, and prepares prior authorization packets for payers. It reduces clinicians’ workload, but its possible failures include invented text in a note, a refill that should not happen, advice given without a clinician, and patient information sent to the wrong person.
In the assistant’s register of actions (P9), rules that come from law are marked with their source.
| Action | Rule | Decision | Evidence and authority |
|---|---|---|---|
| Draft a visit note in the draft area | Allowed; source audio retained | Permit | Recording consent on file |
| Enter a note in the signed medical record | The treating clinician attests; audio kept until signed and for [retention period] | Hold | Treating clinician |
| Schedule, reschedule, or cancel a visit | Within open slots | Permit | None needed |
| Answer logistics questions | Approved text only: hours, directions, forms | Permit | Approved text library |
| Reply with clinical advice | A clinician reviews. Urgent symptoms go straight to nurse triage. | Hold | Clinician on duty |
| Refill a non-controlled maintenance medication | Within the clinic’s standing refill protocol where state law allows; otherwise the prescriber decides | Permit / Hold | Protocol; prescriber |
| Refill a Schedule II controlled substance | Prohibited by 21 CFR 1306.12(a); routed to the prescriber | Deny | None |
| Refill a Schedule III or IV controlled substance | The prescriber decides; never beyond five refills or six months (21 CFR 1306.22) | Hold / Deny | Prescriber |
| Disclose records for purposes other than treatment, payment, or health care operations | The privacy office reviews. The patient’s authorization is required (45 CFR 164.508) unless the Privacy Rule otherwise permits the disclosure. | Hold / Deny | Privacy office |
| Submit a prior authorization packet | Complete, and signed by the ordering clinician | Permit | Ordering clinician |
| Place orders for labs, imaging, or medication | The ordering clinician signs | Hold | Ordering clinician |
The same pattern governs coverage decisions, and the law increasingly requires it. CMS told Medicare Advantage plans in February 2024 that an algorithm may assist a coverage determination but may not decide it from a larger data set in place of the individual patient’s medical history, the physician’s recommendations, or clinical notes. Nor may an algorithm alone end post-acute care or deny an admission. California’s SB 1120, in effect since 1 January 2025, requires that only a licensed physician or licensed health care professional deny, delay, or modify care based on medical necessity. Texas, Maryland, Arizona, Washington, and Iowa have since passed rules along similar lines. CMS’s WISeR model, which adds prior authorization for selected services in traditional Medicare in six states from 2026, says that all recommendations for non-payment are determined by appropriately licensed clinicians.
The layer treats a denial that a model recommends as a proposal. It holds the denial for a licensed reviewer, with the patient’s own record attached as evidence, and never permits it automatically.
rule: adverse-determination
applies to: coverage.deny, coverage.reduce, coverage.delay
when: basis includes medical necessity
decide: hold for licensed physician or licensed health care professional
evidence: the member's own history, physician recommendation, clinical notes
never: permit without a named reviewer's decisionReview of drafted notes. People who approve many machine drafts tend to over-rely on them, which the EU AI Act calls automation bias. Clinics should highlight low-confidence passages, audit a sample of signed notes against the audio, and track how often drafts are signed unchanged.