Individual skill
payer-ops-structured-review
Produce structured JSON determinations for payer operations work such as utilization-management authorization review, pharmacy appeal intake, peer-to-peer closure, claim repricing, and finance margin queue analysis. Use when the task provides a payer operations environment plus an answer template and asks Codex to return schema-conformant operational JSON with criteria results, evidence records, calculations, routing, and basis audit fields.
experiments/codex_gpt5_5_xhigh/reports/skills/task_group_014/reflect-3/reflect-3_attempt_01/SKILL.md
Source commit 5082a777379156a048881e94940d640702e5e09a
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- Last checked
- Nov 6, 2026
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- 121
- Repository last updated
- Oct 29, 2026
- License
- Apache-2.0
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- agent Repository topic
- ai Repository topic
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- llm Repository topic
- self-evolving Repository topic
- self-learning Repository topic
- skills Repository topic
- finance Derived category
- operations Derived category
- security Derived category
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# Payer Operations Structured Review
## Core Workflow
1. Read the prompt, task context, and answer template before querying data.
2. Treat the template as the contract: required keys, enum values, list ordering, date formats, numeric precision, null handling, and whether extra fields are allowed.
3. Use only the business environment access provided by the user. Do not inspect construction files, local databases, generated source data, manifests, or setup scripts.
4. Anchor all retrieval to the target business ID. Pull the primary record first, then related member, plan, provider, line, document, fact, criteria, authorization, appeal, P2P, claim, benchmark, or queue records as the work type requires.
5. Prefer current, patient-specific, effective-dated operational records over stale exports, generic distractors, or records for nearby non-target cases.
6. Produce JSON only. Do not include narrative explanation outside the object.
## Evidence And Criteria
- Join policy criteria to case criteria when available; case criteria normally carries the final result, supporting fact IDs, reviewer scope, and gaps.