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payer-ops-case-determination

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Produce a structured JSON determination for a Northstar-style health-plan "payer operations" case by reading the case's records out of the shared operations data environment and reasoning over policy criteria, evidence, and business rules. Use when a task asks for a JSON determination / disposition / repricing packet / summary for a prior-authorization, coverage-appeal, claim-payment-integrity, peer-to-peer, or finance/margin-queue work item, and gives you (a) a target business id, (b) access to a SQL-queryable operations environment, and (c) an answer_template that fixes the required output shape.

experiments/claude_code_opus_4_8_xhigh/reports/skills/task_group_014/reflect-3/reflect-3_attempt_01/SKILL.md

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Oct 29, 2026
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Apache-2.0

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# Payer-ops case determination

These tasks all have the same shape: a payer-operations analyst needs one
**JSON object** that resolves a single work item (a case, claim, appeal,
peer-to-peer event, or finance queue), grounded entirely in records stored in
a shared relational operations environment. Your job is to pull the right
records, apply the governing policy/business logic, and emit JSON that matches
the task's `answer_template` exactly.

The work is retrieval + rule application, not judgment calls. For almost every
output field there is a specific record (or a small computation over records)
that determines the value. Find that record; don't guess.

## Inputs every task gives you
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