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northstar-payer-ops

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Northstar Health Plan payer-operations structured determinations. Use when a task asks for a JSON determination, disposition, correction packet, P2P summary, or margin-queue summary for a Northstar case/appeal/claim/P2P/queue against a shared read-only payer environment (base URL http://task-env:9014/, SQL POST /sql/query with bearer pa-review-token-014, open GET business endpoints). Covers five archetypes — UM nurse prior-auth determination (physical therapy), pharmacy coverage appeal + manufacturer assistance intake, payment-integrity claim repricing (cardiac imaging), peer-to-peer final summary (PET MPI), and UM-finance therapy margin queue. Reads prompt.txt + task_context.json + answer_template.json, gathers evidence via allowed endpoints only, and emits exactly one JSON object matching the template's required keys, enums, ordering, precision, and basis_audit rules. Do not inspect environment DB/setup files directly; do not call any judge endpoint.

experiments/claude_code_glm_5_2_max/reports/skills/task_group_014/self/self_attempt_03/SKILL.md

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Oct 29, 2026
License
Apache-2.0

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# Northstar Payer Operations Determinations

Produces one structured JSON object for Northstar Health Plan payer-operations work items: utilization-management (UM) prior-auth determinations, pharmacy coverage appeals with manufacturer assistance intake, payment-integrity claim repricing, peer-to-peer (P2P) final summaries, and UM-finance margin-queue summaries.

Each work item is self-describing: the task directory tells you the intent, the target identifiers, and the exact output contract. Your job is to gather evidence from the shared read-only environment, apply the domain rules, and return one JSON object that conforms to the contract.

## When to use

A task matches this skill when it references the **Northstar** payer-operations environment and asks for a structured JSON result for one of these work items:

- **UM nurse determination** — prior authorization case, typically physical therapy (`CASE-…`).
- **Pharmacy appeal + assistance** — coverage exception appeal with a manufacturer assistance screen (`APPEAL-…` / `APL-…`).
- **Payment-integrity claim repricing** — a paid claim repriced against a benchmark schedule, typically cardiac imaging (`CLAIM-…`).
- **Peer-to-peer summary** — final P2P determination after a completed discussion, typically cardiac imaging PET MPI (`P2P-…`).
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