Cedar Ridge Intake Reconciliation

Cedar Ridge Intake Reconciliation

Core Workflow

1. Read the user prompt and every file under input/payloads/ before querying the portal. Treat answer_template.json as the source of truth for required keys, constants, controlled values, list ordering, nullability, and summary fields.
2. Use the base URL from environment_access.md. Use only the listed Cedar Ridge endpoints and the read-only POST /query endpoint.
3. Scope records from the prompt/template: roster ID, referral batch ID, transfer batch ID, program code, and any required patient/referral/transfer IDs. Do not reuse IDs, dates, counts, or row outcomes from prior examples.
4. Prefer one POST /query SELECT with joins for batch work, then use REST endpoints for spot checks:
   • patients, clinical_history, chart_artifacts
   • intake_rosters, coverage, pbm, patient_pharmacy, pharmacies, lifestyle
   • referrals, icd_codes, documents
   • transfer_requests, facility_capacity
   • program_candidates
5. Build intermediate issue sets per patient/referral/transfer. Derive summaries from the final rows, not from separate assumptions.
6. Validate the final object against the template: required keys present, constants copied from the template/prompt, enum values allowed, lists ordered as specified, count fields internally consistent, and no prose outside JSON.

Use /query like:

curl -sS -X POST "$TASK_ENV_BASE_URL/query" \
  -H 'Content-Type: application/json' \
  -d '{"sql":"SELECT ..."}'

Check row_count and truncated; rerun narrower queries if needed.

Access Roster Rules

For new-patient access or registration rosters, query intake_rosters by roster ID and join patient, coverage, PBM, preferred pharmacy, lifestyle, and clinical history.

• Coverage is valid only when a coverage row exists, status is active, the requested service date is within the effective/termination window, network is acceptable, and the roster service line appears in the coverage service-line list.
• Coverage blockers map from the failing field: expired/terminated coverage, pending coverage, excluded service line, or missing coverage. Missing address is a separate demographic blocker.
• PBM is valid only when the PBM row exists, is active, approved, covered by formulary, and matches the medical coverage payer/policy. Map inactive/rejected/pending/review/not-found states to PBM invalid, absent rows to PBM missing, and payer/policy mismatch to PBM policy mismatch.
• Preferred pharmacy status comes from patient_pharmacy rank 1 joined to pharmacies.network_status; use unknown when no preferred pharmacy can be verified.
• Preferred-contact blockers apply when the preferred channel is unusable: email requires email, phone/sms requires phone, and portal requires an active/existing chart. Emergency-contact absence is its own blocker.
• Lifestyle risk is high for current smoking, heavy alcohol use, no/unknown exercise, or short sleep; medium for former smoking, moderate alcohol, mild sleep/exercise concerns; low only when no material lifestyle concern is present.
• Overall risk is high for high lifestyle risk, recent hospitalization, nonempty clinical risk flags, complex medication burden, or multiple serious chronic conditions; medium for moderate lifestyle/clinical burden; low otherwise. Add the high-risk blocker when overall risk is high.
• Registration disposition should follow severity: reject for disqualifying coverage such as expired coverage or excluded service line; clinical review for high clinical risk or clinical/PBM conflicts; hold for administrative or pending items when not otherwise rejected/reviewed; approve only when no blockers remain.

Referral Audit And Activation Rules

For referral batches, query referrals by batch_id, join icd_codes, and join patients/chart artifacts when chart activation is requested.

• Clinical code discrepancies:
  • Flag service-family mismatch when icd_codes.service_family does not match the referral service line.
  • Flag chapter mismatch when the task expects a service-line ICD chapter and icd_codes.chapter falls outside it. Orthopedic readiness tasks commonly expect musculoskeletal M00-M99; injury S00-T88 codes should be reviewed unless the task explicitly accepts trauma/injury.
  • Flag narrative mismatch when diagnosis_description or referral_reason is clinically inconsistent with the ICD description/service line.
  • Flag laterality mismatch when left/right terms in the referral text conflict with icd_codes.laterality.
• Referral blockers:
  • records_received = 0 means records missing.
  • imaging_received = 0 means imaging missing when the template tracks imaging.
  • auth_required = 1 with status pending, denied, or not submitted is an authorization blocker.
  • appointment_scheduled = 1 before clearance requires appointment/scheduled-before-clearance review.
• Duplicate handling:
  • Group same-patient duplicate referrals in the same batch when patient, insurance, ICD/reason, or fax/phone indicates a repeated referral; keep the earliest/lowest referral ID unless the portal notes identify a primary.
  • Treat shared insurance IDs across different patients as shared-insurance anomalies, not ordinary duplicate referrals.
  • If rows are only marked possible duplicates but patient/insurance/clinical facts do not match, clear duplicate review when the template has such a field.
• Readiness precedence:
  • ready: no clinical, administrative, authorization, records, imaging, duplicate, or appointment issues.
  • blocked: records/imaging/auth blockers, even if clinical issues also exist.
  • under_review: clinical code/narrative/laterality, duplicate, or scheduled-before-clearance issues without hard missing/auth blockers.
  • admin_followup: insurance/admin-only anomalies.
• Priority:
  • Tier 1 for urgent clinical-code, service-family, narrative, or laterality issues.
  • Tier 2 for hard blockers, routine clinical review, duplicate consolidation, or scheduled-before-clearance work.
  • Tier 3 for administrative-only follow-up.
  • Rank non-ready referrals by tier, then scheduled-before-clearance/urgent safety concerns, then ascending referral ID unless the template says otherwise.
• Action/correspondence mapping: code discrepancies need corrected ICD or clinical-code clarification; narrative issues need narrative confirmation; laterality issues need laterality confirmation; duplicates need consolidation or duplicate-resolution correspondence; shared insurance needs policy verification; missing records/imaging/auth need the matching request or authorization action; scheduled-before-clearance needs appointment hold/review.
• Chart activation for ready referrals: inspect chart_artifacts. Create/update required artifacts that are missing or stale. Existing charts generally need update actions; patients without charts need create actions. Sort artifact lists as the template requires.

Dialysis Transfer Rules

For transfer batches, query transfer_requests, related documents, and facility_capacity.

• A required packet document is present only when a matching document row exists for the transfer, status is final, and finalized = 1. Draft, non-final, and absent rows are missing.
• Treat transportation as satisfied by the transfer row when the template includes it; null/empty transportation is missing.
• Sort missing document codes alphabetically unless the template specifies another order.
• Freshness is measured from each transfer's requested start date. Use these default limits unless the template overrides them:
  • hbsag, monthly_labs, ppd_or_cxr: 30 days
  • history_physical, hep_b_antibody_core: 365 days
• Capacity is available only when facility_capacity has open chairs for the exact requested start date and modality. Sum open chairs across locations.
• Feasibility values follow packet readiness and capacity:
  • packet complete/fresh and capacity available: ready on requested start
  • packet incomplete or stale and capacity available: packet not ready, capacity available
  • packet incomplete or stale and capacity unavailable: packet not ready, capacity unavailable
  • packet ready and capacity unavailable: capacity unavailable
• Intake decision/contact:
  • Accept only when packet is complete/fresh and capacity is available.
  • Hold when the packet is ready but scheduling/capacity or admin-only work remains.
  • Clinical review when any clinical packet document is missing or stale.
  • Route clinical packet gaps to the clinical nurse/referring facility, admin/insurance/transportation gaps to intake or patient contact, capacity-only work to scheduling/internal queue, and accepted cases to none.

Program Enrollment Rules

For program panels, get candidates from /programs/{program_code}/candidates or program_candidates, then join patients, clinical history, and chart artifacts. Include every current candidate returned for the program and sort as the template specifies.

• Use an explicit as-of date from the prompt/template/portal metadata when present. Do not derive it from the maximum candidate date. If no date is exposed, use the task's stated current panel date.
• Determine target-condition eligibility from target_condition and clinical_history.chronic_conditions. Common mappings: diabetes-hypertension requires both diabetes and hypertension; renal-diabetes requires diabetes plus CKD/renal disease; COPD requires COPD; CAD/cardiology programs require CAD/cardiac history.
• Consent and chart status affect disposition but do not by themselves change target-condition eligibility.
• Reason-code mapping:
  • Add the program criteria code when the target condition is met.
  • Add high-touch codes for recent hospitalization, recent ED risk flags, or low adherence when the template allows them.
  • Add CKD/renal monitoring codes when CKD is present and no higher-touch cadence applies.
  • Add consent declined/missing, chart not active, stale active problems, missing recent vitals/labs/medications, wrong target condition, and missing active diagnosis codes from the corresponding candidate/chart/history facts.
• Disposition:
  • Enroll eligible candidates with signed consent and required current chart artifacts.
  • Hold eligible candidates with missing consent or remediable chart gaps.
  • Reject ineligible candidates and candidates who declined consent, unless the template instructs a different disposition.
• Missing chart artifacts should include only allowed template values. For eligible chart-gap cases, include chart_record when no active chart exists; include stale/missing active problems, vitals, labs, medications, and consent as applicable. For ineligible rejections, avoid adding chart artifacts unless the template specifically asks for chart remediation.
• Outreach uses preferred_outreach only if usable: portal requires an existing chart, email requires email, and phone/sms requires phone. If unusable, fall back to patient preferred contact, then any available channel, then none.
• Monitoring package:
  • High-touch packages for hospitalization, ED, or low-adherence high-touch cases; weekly cadence and early check-in.
  • Standard packages for routine eligible candidates; monthly cadence unless CKD/renal monitoring sets biweekly cadence.
  • Deferred package with consent/chart update components for holds.
  • Not applicable package with no components for rejected/ineligible candidates.

Final JSON Checks

• Use constants from the template and prompt for task_id, batch_id, roster_id, program_code, service date, and service line.
• Preserve required list ordering exactly: usually ascending ID, alphabetical code, or explicit priority rank.
• Treat issue/reason/blocker arrays marked unordered as sets: no duplicates; use only allowed enum strings.
• Include zero counts for every required count key, even when absent from the data.
• Recompute summary counts from the final rows after all status decisions are complete.
• Return JSON only when the prompt asks for JSON only.