A program-level requirements traceability matrix binding every functional requirement across the three workstream Business Requirements Documents — BRD-01 Claims & Prior Authorization, BRD-02 Member & Provider Experience and BRD-03 Underwriting & Risk — to a priority, a verification method and an acceptance gate. Each BRD already carries its own regulatory traceability matrix (regulation → requirement); what did not exist until now is the program matrix that a reviewer uses to ask a single question across all three workstreams at once: is every requirement we committed to going to be proven, and how.
01 Purpose & how this matrix is built
On a $99M, three-year, three-workstream AI transformation, the requirements do not live in one document — they live in three BRDs written for three different parts of the business, each with its own AI models, its own regulatory drivers and its own delivery team. That separation is correct: a claims prior-authorization requirement and an underwriting-risk requirement should not be forced into one document to satisfy a tool. But it creates a gap. No single artifact answers the cross-workstream question a steering committee actually asks — across everything we have committed to, what is the coverage, and where is the risk? This matrix is that artifact.
It is built by extraction, not by hand. Every requirement below is pulled directly from its BRD's Functional Requirements section; the identifier, the MoSCoW priority and the statement are the BRD's own. The verification method is derived from what each requirement does — a fairness requirement is proven by fairness testing, an integration requirement by integration testing — and cross-checked against the testing model each BRD already specifies in its own Section 12. A hand-maintained RTM drifts from its sources the moment either changes; a derived one is wrong only if its sources are wrong, and says so loudly when they move.
02 Coverage summary
| Workstream | BRD | Functional reqs | Must | Traced to a method |
|---|---|---|---|---|
| Claims & Prior Authorization | BRD-01 | 17 | 15 | 17 |
| Member & Provider Experience | BRD-02 | 20 | 18 | 20 |
| Underwriting & Risk | BRD-03 | 12 | 12 | 12 |
| Program total | 49 | 45 | 49 |
03 Verification method distribution
The spread of methods is itself a finding. This is an AI program, and it shows: model-accuracy validation, fairness testing, explainability and adversarial testing together account for a large share of the verification effort — methods that a conventional software RTM would not contain at all. A requirements matrix that traced these requirements only to "unit test / integration test" would be hiding exactly the risk that makes this program an AI program.
| Verification method | Requirements |
|---|---|
| Model accuracy / independent validation | 12 |
| Unit + integration testing | 11 |
| UAT (business acceptance) | 10 |
| Integration testing | 6 |
| Fairness / bias testing | 4 |
| Explainability validation | 3 |
| Security & compliance testing | 2 |
| Performance testing | 1 |
04 BRD-01 — Claims & Prior Authorization (17 FRs)
Traces to the acceptance gate in BRD-01 §13: accepted into production when all Must requirements are implemented and tested, all five AI models pass independent validation with zero uncorrected High findings, fairness testing passes within the demographic-deviation threshold, and UAT passes.
| Req ID | Requirement (from BRD-01 §5) | Priority | Verification method |
|---|---|---|---|
| FR-01.001 | System shall accept PA requests via HL7 FHIR R4 Prior Authorization Support (PAS) API, conforming to Da Vinci PAS Implementation Guide v2.0+. API must support create, update, status inqui… | Must | Integration testing |
| FR-01.002 | System shall accept PA requests via ACME's existing provider portal, maintaining backward compatibility with current submission workflows during transition period (minimum 12 months post-… | Must | Integration testing |
| FR-01.003 | System shall accept PA requests received via fax, using OCR + NLP to extract structured data (member ID, provider NPI, service codes, clinical documentation) from unstructured fax images.… | Should | Model accuracy / independent validation |
| FR-01.004 | System shall parse unstructured clinical documentation (physician notes, lab results, imaging reports) submitted with PA requests and extract relevant clinical evidence using NLP. Extract… | Must | Unit + integration testing |
| FR-01.005 | System shall automatically verify member eligibility, benefit coverage, and service authorization requirements at intake, flagging requests that fail eligibility checks before clinical re… | Must | Unit + integration testing |
| FR-01.006 | System shall classify each PA request by urgency (standard / urgent / retrospective), service category (medical, surgical, behavioral health, pharmacy, DME), and complexity (routine / com… | Must | Model accuracy / independent validation |
| FR-01.007 | System shall evaluate each PA request against ACME's medical policy guidelines using a combination of rules-based logic (for deterministic policy criteria) and ML prediction (for probabil… | Must | Model accuracy / independent validation |
| FR-01.008 | System shall auto-approve PA requests that meet ALL of the following criteria: (a) confidence score ≥ 95%, (b) request matches at least one existing approved-case pattern in the training … | Must | Model accuracy / independent validation |
| FR-01.009 | System shall route all requests with confidence score | Must | Model accuracy / independent validation |
| FR-01.010 | System shall route requests with confidence score 85%–94% to a "verify" queue where a human reviewer confirms or overrides the AI recommendation with a streamlined review (target: 5–10 mi… | Must | Explainability validation |
| FR-01.011 | System shall issue PA determinations within the CMS-0057-F timelines: 72 hours for urgent requests, 7 calendar days for standard requests. System shall track elapsed time from submission … | Must | UAT (business acceptance) |
| FR-01.012 | System shall generate a structured, human-readable explanation for every determination (approval or denial). Explanation shall include: the specific clinical evidence evaluated, the speci… | Must | Explainability validation |
| FR-01.013 | System shall communicate determinations to providers via the FHIR PAS API (real-time response), provider portal notification, and member notification (portal + letter). Denial letters sha… | Must | Integration testing |
| FR-01.014 | System shall support the HL7 Da Vinci Coverage Requirements Discovery (CRD) flow, enabling providers to check PA requirements before submitting a request. CRD responses shall indicate whe… | Should | Unit + integration testing |
| FR-01.015 | System shall maintain a complete audit trail for every PA decision: timestamp, request data hash, model version used, confidence score, preliminary recommendation, human reviewer action (… | Must | Explainability validation |
| FR-01.016 | System shall generate the CMS-0057-F public reporting metrics: PA submission volume (by service category), approval rate, denial rate, average decision time (standard and urgent), and app… | Must | Performance testing |
| FR-01.017 | System shall support quality audit sampling: a configurable percentage of auto-approved cases (default: 5%) shall be randomly selected for retrospective human clinical review. Audit resul… | Must | Unit + integration testing |
05 BRD-02 — Member & Provider Experience (20 FRs)
Traces to the acceptance gate in BRD-02 §13. This is the most requirement-dense workstream, and the one where UAT carries the heaviest load — member- and provider-facing experience is proven by the people who use it, not only by the models behind it.
| Req ID | Requirement (from BRD-02 §5) | Priority | Verification method |
|---|---|---|---|
| FR-02.001 | Virtual assistant shall support conversational interactions across web (ACME member portal), mobile app (iOS and Android), and voice (phone channel with IVR integration) with unified conv… | Must | Integration testing |
| FR-02.002 | Virtual assistant shall handle all 7 supported routine inquiry types (benefits verification, claims status, PA status, provider search, ID card request, general plan information, cost est… | Must | UAT (business acceptance) |
| FR-02.003 | Virtual assistant shall identify itself as an AI assistant at the beginning of every interaction and offer the option to speak with a human agent. Disclosure text: "Hi, I'm ACME's virtual… | Must | UAT (business acceptance) |
| FR-02.004 | Virtual assistant shall authenticate the member before accessing any member-specific data (claims, benefits, PA status). Authentication shall use the same multi-factor methods as the exis… | Must | Security & compliance testing |
| FR-02.005 | Virtual assistant shall ground every factual response in an authoritative ACME source document. The system shall cite the source in its response (e.g., "According to your Gold Plan Summar… | Must | UAT (business acceptance) |
| FR-02.006 | If the retrieval step does not identify a relevant passage from the verified source corpus with a retrieval confidence score ≥ 90%, the system shall NOT attempt to generate a response. In… | Must | Model accuracy / independent validation |
| FR-02.007 | The generation component of the RAG pipeline shall be constrained to use only information present in the retrieved passages. The system shall not extrapolate, infer, or synthesize informa… | Must | Unit + integration testing |
| FR-02.008 | The verified source corpus shall be maintained by ACME's medical policy and benefits administration teams — not by the AI system or the delivery team. The corpus shall be versioned, and t… | Must | UAT (business acceptance) |
| FR-02.009 | Virtual assistant shall detect member emotional distress signals (frustration language, repeated escalation requests, profanity, expressions of confusion or helplessness) using the sentim… | Must | UAT (business acceptance) |
| FR-02.010 | When a member explicitly requests a human agent — through any phrasing ("talk to a person," "connect me to someone," "I want a real person," "agent," "representative," etc.) — the system … | Must | UAT (business acceptance) |
| FR-02.011 | All escalations from virtual assistant to human agent shall be warm transfers: the agent receives the full conversation history, member authentication status, member history summary, and … | Must | Security & compliance testing |
| FR-02.012 | If escalation is requested outside business hours (when no live agents are available), the system shall offer two options: (a) schedule a callback for the next business day with the inqui… | Must | UAT (business acceptance) |
| FR-02.013 | Agent-assist tool shall provide real-time response suggestions in a side panel visible to the agent during live calls. Suggestions shall be generated from the same verified source corpus … | Must | UAT (business acceptance) |
| FR-02.014 | Agent-assist tool shall display a member history summary at call start: recent calls (last 90 days with topic), open claims and status, open PAs and status, recent portal activity, and an… | Must | Integration testing |
| FR-02.015 | Agent-assist tool shall generate a real-time case summarization as the call progresses, capturing: key topics discussed, member requests, agent commitments, actions taken, and recommended… | Must | Unit + integration testing |
| FR-02.016 | Agent-assist tool shall detect call sentiment in real-time and display a sentiment indicator (neutral / positive / frustrated / distressed) visible to the agent. If sentiment is "distress… | Should | UAT (business acceptance) |
| FR-02.017 | Agent-assist tool shall track agent usage patterns: which suggestions are accepted, modified, or ignored. Usage analytics reported monthly to BRD-02 product team for model improvement and… | Should | Unit + integration testing |
| FR-02.018 | System shall maintain a complete audit trail for every virtual assistant interaction: session ID, member ID (authenticated), timestamps, full conversation transcript (member messages + sy… | Must | Model accuracy / independent validation |
| FR-02.019 | System shall support quality audit sampling: a configurable percentage of virtual assistant interactions (default: 5%) randomly selected for human review. Reviewers assess: factual accura… | Must | Model accuracy / independent validation |
| FR-02.020 | System shall generate operational reporting: daily/weekly/monthly volumes (by channel, inquiry type, resolution type), escalation rate, resolution rate, average interaction duration, memb… | Must | Integration testing |
06 BRD-03 — Underwriting & Risk (12 FRs)
Traces to the acceptance gate in BRD-03 §13. Every requirement here is Must-priority — there is no discretionary scope in underwriting and risk, because a risk model that is "mostly" governed is not governed. Explainability and independent model validation dominate its verification, which is correct for a workstream whose outputs drive pricing and coverage decisions.
| Req ID | Requirement (from BRD-03 §5) | Priority | Verification method |
|---|---|---|---|
| FR-03.001 | System shall produce an AI Risk Score (0–100) for every underwriting application (group and individual), calibrated against ACME's historical loss experience. Score shall be accompanied b… | Must | Model accuracy / independent validation |
| FR-03.002 | System shall produce a Top Risk Factors report for every scored application: the 5–10 variables that most influenced the risk score, with relative contribution percentages summing to ≥ 80… | Must | Model accuracy / independent validation |
| FR-03.003 | System shall produce a Comparable Case Analysis: 3–5 historical cases with the most similar risk profiles and their actual 12-month and 24-month loss outcomes. Similarity metric and selec… | Must | Unit + integration testing |
| FR-03.004 | System shall flag applications exhibiting anomaly patterns associated with adverse selection (e.g., sudden increase in high-cost service utilization before coverage effective date, enroll… | Must | Fairness / bias testing |
| FR-03.005 | System shall NOT use any protected characteristic — race, color, national origin, religion, sex, sexual orientation, disability, gender identity, or marital status — as a direct input var… | Must | Fairness / bias testing |
| FR-03.006 | System shall support two underwriting modes: (a) Group underwriting (for employer groups of 2–10,000+ employees, using census demographics, industry classification, and claims history whe… | Must | Fairness / bias testing |
| FR-03.007 | AI risk assessment shall be delivered to actuaries within the existing underwriting system interface — as an embedded panel, not a separate application. The actuary shall see the AI score… | Must | Model accuracy / independent validation |
| FR-03.008 | System shall capture the actuary's response to the AI assessment: accepted (used score as-is), adjusted (modified score with documented reason), or overridden (disregarded score with docu… | Must | Unit + integration testing |
| FR-03.009 | No pricing decision shall be automated — every premium rate requires actuarial sign-off. The AI system is an input to the actuary's decision, not a replacement for it. The system shall no… | Must | Unit + integration testing |
| FR-03.010 | System shall maintain a complete audit trail for every risk assessment: application ID, model version, input data hash, risk score, predicted loss ratio, confidence interval, top risk fac… | Must | Model accuracy / independent validation |
| FR-03.011 | System shall generate regulatory reporting: model methodology documentation (suitable for state insurance department examination), fairness testing results (per NAIC bulletin and Colorado… | Must | Fairness / bias testing |
| FR-03.012 | System shall support actuarial model documentation per ASOP No. 56 (Modeling): model purpose, methodology, data sources, assumptions, limitations, and sensitivity analysis. Documentation … | Must | Unit + integration testing |
07 Traceability gaps — recorded, not hidden
An RTM that reports complete coverage on a program in early execution is not being maintained. These are the genuine open items this matrix surfaces — each is a real finding about the current state of the requirement baseline, not a defect in the requirements themselves.
| # | Gap | Why it matters |
|---|---|---|
| G-01 | Non-functional requirements are specified in prose, not as traceable IDs. Each BRD's §9 states performance, security and availability requirements in narrative form (e.g. "P95 latency ≤ 2 seconds"), but they carry no NFR-##.### identifier the way functional requirements do. | An NFR that cannot be referenced by ID cannot be individually traced to a test or an acceptance criterion — it can only be verified in aggregate. For a program with hard latency and availability commitments, that is a real traceability gap, and the honest place to record it is here. |
| G-02 | No downstream artifact yet references functional requirement IDs. The Master Test Strategy, the resource-loaded WBS and the Benefits Realization Plan describe the work in their own terms, but none currently cites an FR-##.### identifier, so the trace from requirement to test case and to schedule task is not yet closed in those documents. | This matrix closes the requirement→verification-method trace; closing the requirement→test-case and requirement→schedule traces requires those artifacts to adopt the FR IDs. Recording it keeps the next increment of traceability visible rather than assumed. |
| G-03 | Fairness, human-in-the-loop and responsible-AI requirements live in dedicated BRD sections (§10, §11), separate from the functional requirements in §5. They are governed, but they are not enumerated as FRs, so this matrix traces them by method rather than line by line. | These are the requirements most specific to an AI program and most scrutinised by regulators. A future increment should give them first-class IDs so each can be traced individually — the same treatment the functional requirements already receive. |
08 How to read this matrix against the program
The chain this matrix sits in is: business case (CBA) → workstream requirements (the three BRDs) → this RTM → verification (Master Test & QA Strategy) → acceptance (each BRD §13) → realized benefit (Benefits Realization Plan). This matrix is the hinge between what was asked for and how it will be proven. It reconciles to the BRDs on the left — every requirement ID here exists there — and to the Test Strategy's verification levels on the right. When a BRD requirement changes, this matrix is regenerated from it; when the Test Strategy adds a verification level, the method column is revisited. That is what keeps a traceability matrix a live control rather than a snapshot that quietly goes out of date.