Individual skill
payer-ops-structured-determination
Produce the exact structured JSON deliverable for a Northstar-style payer-operations task by reading a shared read-only case environment. Use this when a task hands you a target business ID (a case, appeal, claim, peer-to-peer event, or finance queue), a read-only operations environment (a SQL query endpoint plus business GET endpoints), and a JSON answer template to fill. Covers prior-authorization / UM nurse determinations, coverage-exception appeals with manufacturer-assistance intake, claim repricing against rate benchmarks, peer-to-peer closures, and margin-queue analysis.
experiments/claude_code_opus_4_8_xhigh/reports/skills/task_group_014/reflect-3/reflect-3_attempt_03/SKILL.md
Source commit 5082a777379156a048881e94940d640702e5e09a
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- Oct 29, 2026
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- Apache-2.0
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- agent Repository topic
- ai Repository topic
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- self-evolving Repository topic
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- finance Derived category
- operations Derived category
- data Derived category
- data-databases Derived category
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SKILL.mdcore · 6,905 bytesSKILL.mdcore · 6,905 bytesSKILL.mdcore · 6,905 bytesreference/basis_audit.mddoc · 2,356 bytesreference/data_model.mddoc · 5,165 bytesreference/task_families.mddoc · 7,493 bytes
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# Payer-operations structured determination
You are acting as a payer-operations analyst (UM nurse, appeals coordinator, payment-integrity
analyst, peer-to-peer coordinator, or UM-finance analyst). The task gives you one target
business entity and an **answer template**, and asks for a single JSON object that a downstream
team will act on. Your job is to pull the relevant records from the shared environment, apply
the operational decision rules, and emit JSON that matches the template's contract exactly.
Getting a high score depends on two things equally: **the right business decision** and **exact
conformance to the output contract** (every required field, correct enum spelling, correct
ordering, correct numeric precision, `null` vs `""`). Treat both as first-class.
## Inputs you are given
