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payer-ops-determination

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Use for Northstar-style payer-operations "structured determination" tasks: read a prompt plus task_context.json and answer_template.json, query a shared read-only payer-operations data environment (cases, members, plans, policies, criteria, documents, authorizations, appeals, drug trials, assistance screens, claims, payment benchmarks, P2P events, service-margin rows), apply the business rules, and return exactly one strict JSON object matching the template — including a basis_audit trail. Covers prior-authorization nurse determinations, pharmacy coverage appeals + manufacturer-assistance intake, claim repricing/benchmark validation, peer-to-peer (P2P) final summaries, and finance margin-queue analyses.

experiments/claude_code_opus_4_8_xhigh/reports/skills/task_group_014/reflect-3/reflect-3_attempt_02/SKILL.md

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Oct 29, 2026
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Apache-2.0

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# Payer-Operations Structured Determination

A task in this family gives you a business target (a case / appeal / claim / queue id),
access to a shared payer-operations data environment, and a strict output contract. Your
job is to pull the relevant records, apply the operational rules, and emit one JSON object
that matches `input/payloads/answer_template.json` exactly.

The specific business decision differs per task, but the **shape of the work is always the
same**. Follow this procedure.

## 1. Read the three inputs before touching the environment

- **`prompt.txt`** — the business ask and any special instructions (ordering, null rules,
  currency rounding, date-window rules, which records to include/exclude).
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