Coverage authority, payment authority, audit and appeals sit in separate bodies, because concentrating them would make a coverage mistake, a payment mistake and a governance mistake mutually reinforcing. The cost brake runs in two stages and both read access-adjusted spending, so a fall caused by undelivered care never registers as a saving. Prior authorization is abolished and replaced by retrospective, collective review. Durability is engineered: universality, mandatory appropriation, ring-fenced capital, insulated rate-setting.
National rules require national due process. Medical societies, patient organizations, manufacturers, Authorities, clinicians and AHQB staff may petition for a new or revised determination. New scientific evidence or material misinterpretation of the existing record is sufficient ground.
A patient may also petition directly, on a low threshold and a short clock.
Without a direct individual channel, a patient whose clinician declines to file has no route below the federal tribunal. That is a gap that would swallow the appeal right for exactly the people least able to navigate it.
The clock matters more than the standard. In any coverage system with a deadline, the deadline becomes the denial mechanism unless missing it costs the agency something.
The institutional docket runs: published evidence submission, advisory-panel review, public hearing, proposed determination, public comment, and reasoned final decision.
Exceptional-patient determination handles the individual who falls outside a studied indication. A treating clinician requests it; the panel asks whether the person falls outside the studied population, whether a rational biological or clinical basis supports benefit, and whether evidence is sufficient for provisional payment.
Urgent cases carry a short statutory clock and treatment proceeds under provisional payment while review runs. If the panel does not rule within the clock, treatment proceeds and payment stands. Absent that default the clock becomes the denial mechanism. The patient is never billed because a reasonable clinical exception was unsuccessful.
Final national determinations may be challenged before an independent federal health-coverage tribunal and then in federal court. Congress establishes the governing statute, conducts oversight, and may amend benefit categories prospectively. Congress does not hear individual appeals or direct the outcome of a particular case.
AHQB may also narrow an indication when repeated practice shows little benefit, or broaden one when real-world evidence identifies a subgroup with greater benefit. Published catchment-level variation is what makes both visible.
A low-threshold individual petition channel will be flooded.
Probably, and the exceptional-patient panel is resourced on that assumption. The alternative is a right that exists only for patients with an engaged clinician and the literacy to escalate, which is not a right.
Honesty about gaps. Distributed Healthcare has more unresolved specification than other Engines because operational complexity is higher; the items below are flagged for v10.2 specification or for outside expert review.
- Tribunal capacity and staffing at national scale are unmodelled.