Cedar Ridge Intake Reconciliation

Cedar Ridge Intake Coordination reconciliation

These tasks all have the same shape: a healthcare intake-coordination portal exposes read-only data; you must reconcile a named cohort against deterministic business rules and return one JSON object that exactly follows input/payloads/answer_template.json. The template is a strict contract, and the output is machine-graded field-by-field, so precision and normalization matter as much as the logic.

The template is the spec — read it first

Before touching data, read input/payloads/answer_template.json in full and extract:

• Top-level required keys and their order.
• Per-item required keys for every list section.
• Enum allowed_values for each field — you may ONLY emit these controlled values.
• Ordering rules (e.g. "ascending by patient_id", "ascending referral_id", "alphabetical by code", "unordered set", "highest priority first").
• Count-object keys in the summary — every listed key must appear, even when its value is 0.

Mirror the template exactly: same key names, same nesting, same constant values it pins (task_id, roster_id/batch_id/program_code, service line, etc.). Do not add prose, extra keys, or free-text explanation fields. Output JSON only.

Workflow

1. Parse the template (above) and note every field you must produce.
2. Identify the cohort: the roster_id / batch_id / program_code and the exact member IDs. Get member IDs from the prompt, the target payload, or by querying the portal (e.g. a program's candidate list, or all referrals/transfers in a batch). Include a row for every current member and nothing else.
3. Pull data from the portal (see "Portal access"). Prefer the read-only SQL endpoint for bulk pulls and joins; use the REST detail endpoints when you want pre-joined context.
4. Derive per-record fields by applying the rule families below.
5. Detect cross-record anomalies (duplicates, shared insurance) across the whole cohort.
6. Assemble code sets (blocker / reason / issue / action codes) using ONLY the template's enum values; treat these arrays as unordered sets.
7. Assign the status/decision via the decision ladder, then priority tier / cadence.
8. Compute every summary count by iterating your per-record results — never hand-tally. Initialize each enum key to 0 so zero-count keys are present.
9. Normalize and order all lists per the template, then emit JSON only.
10. Self-check: every required key present; every value in-enum; lists ordered; counts reconcile to the rows; IDs uppercase and verbatim.

Portal access

The task's environment file gives a base URL (referred to here as <BASE_URL>). The portal is read-only and needs no credentials. Two equivalent access paths:

• REST GET list + detail endpoints. List endpoints accept filters (e.g. batch id, query, limit). Detail endpoints (/<resource>/{id}) return the record joined with related data (patient, ICD metadata, documents, etc.). A program's members come from its candidates endpoint.
• Read-only SQL via POST <BASE_URL>/query with body {"sql": "SELECT ..."}. Only SELECT is allowed. This is the fastest way to reconcile — discover the schema from sqlite_master, then join tables directly. See references/portal-schema.md.

Pull the whole cohort's supporting rows up front (coverage, pbm, pharmacy, lifestyle, clinical history, documents, chart artifacts, ICD codes, capacity) rather than record-by-record.

Rule families

Apply only those relevant to the current template. Full derivations and enum-mapping tables are in references/rule-cheatsheet.md. Where a task pins a specific service line / service date / "as-of" date, take it from the cohort's own record in the portal (roster/batch/program), not from the calendar.

Coverage / insurance validity

From the coverage row(s) for the requested service line and service date:

• missing — no coverage row.
• valid — status = active AND service line ∈ service_lines AND not expired (termination_date ≥ service date, effective_date ≤ service date).
• invalid — otherwise (expired/terminated, pending, or service line not covered). Reason codes: coverage_expired (expired or terminated before service date), coverage_pending (status pending), excluded_service_line (service line not in service_lines).

PBM / prescription validity

From the pbm row: valid when active = 1 AND formulary_status = covered AND status = approved AND the PBM policy number matches the coverage policy number. Codes: pbm_missing (no row), pbm_policy_mismatch (policy differs / specialty mismatch flag), pbm_invalid (not active / not covered / not approved).

Preferred pharmacy network

Take the patient's rank-1 preferred pharmacy (lowest preference_rank) and read its network_status: in_network / out_of_network; unknown (code pharmacy_unknown) if none.

Lifestyle & overall risk

Lifestyle risk = count of present risk factors, then bucket: smoking_status = Current (+1), alcohol_use = Heavy (+1), exercise_frequency is None/null (+1), sleep_hours < 6 (+1) → 0 = low, 1–2 = medium, 3+ = high. Overall risk composites lifestyle with clinical acuity (recent_hospitalization, non-empty risk_flags, chronic-condition count). Clinical acuity is usually low in these cohorts, so overall risk skews toward the milder buckets — escalate conservatively rather than defaulting everything to high. overall_risk_high is a reason code when overall risk is high.

Contact / demographic completeness

Flag missing_address (null address), emergency_contact_missing (emergency_contact_present = 0), and preferred_contact_unavailable (the preferred channel's field is null — e.g. prefers email but email is null; prefers phone/sms but phone is null).

ICD coding discrepancies

Resolve icd10_code in icd_codes. A code carries an authoritative service_family, chapter, and laterality. icd_chapter_mismatch = the code's service_family ≠ the referral's service_line (report observed = code chapter, expected = the service line's canonical chapter). A code whose family matches the service line is NOT a chapter mismatch even if its chapter letter differs (e.g. injury S-codes are legitimately orthopedic). laterality_mismatch / narrative_mismatch only when the referral narrative explicitly contradicts the code's laterality / description.

Duplicates & shared insurance (across the cohort)

• Duplicate group = the same patient_id with the same icd10_code on more than one referral. Keep the lowest referral_id as primary; recommend consolidate_to_primary.
• Shared insurance anomaly = the same insurance_id on more than one referral. If the patients differ → verify_distinct_patient_policy_id; if it is the same patient → legitimate_duplicate_same_patient. A shared insurance_id across different patients is NOT a duplicate; a "possible duplicate" note in the data can be a decoy — classify by the rules, not the note.

Operational blockers (referrals)

records_missing (records_received = 0), imaging_missing (imaging_received = 0), authorization_blocked / auth_blocker (auth_required = 1 AND auth_status ∈ {pending, denied, not_submitted}), scheduled_before_clearance / already_scheduled (appointment_scheduled = 1 while not yet cleared).

Document / packet completeness & freshness (transfers)

The template's missing_required_documents enum lists the required document set. A required item counts as satisfied only when present AND finalized (draft/absent → missing). Some doc types are time-limited: a satisfied doc is stale when its age exceeds a freshness limit, where age = (operative reference date − received_date). Use the requested start / service date as the freshness reference (data can carry received dates well after "today"). Freshness limits are portal policy — infer them from the data and use clinical defaults (e.g. monthly labs ≈ 30 days, history & physical ≈ 180, immunology/imaging screens ≈ 365).

Capacity & feasibility (transfers)

Capacity for a requested date = sum of open_chairs across all facility locations for that date and the requested modality; 0 (or no row) → unavailable. Feasibility is the packet × capacity matrix: complete + available → ready-on-start; incomplete + available → packet-not-ready-capacity-available; incomplete + unavailable → packet-not-ready-capacity-unavailable; complete + unavailable → capacity-unavailable.

Chart artifacts & activation

chart_action: create_chart when the patient has no active chart (existing_chart = 0) — list the required artifacts to create; update_chart when a chart exists but required artifact types are absent — list the absent ones; no_chart_action when complete. Order artifacts_to_create alphabetically by the enum string. Distinguish absent artifacts (a row of that type does not exist) from stale ones (a row exists with status = stale) — the template's reason codes model staleness separately from absence.

Program eligibility & enrollment

Eligible when the candidate's target_condition matches the program's condition AND the required active diagnosis is present (else wrong_target_condition / missing_active_dmhtn_diagnosis-style codes). consent_status drives disposition: an active decline blocks enrollment, a missing consent is a recoverable hold. Chart activity + required/fresh artifacts gate a clean enrollment (chart_not_active, stale_active_problems, missing_recent_vitals/labs, missing_medication_list). High-touch triggers (recent hospitalization, recent ED, low adherence, CKD) raise follow-up cadence and the monitoring-package tier and shorten the first check-in.

Decision / readiness ladder & priority tiers

Derive the status from the code set with a fixed precedence:

• Hard operational blocker (missing records/imaging, auth blocked, expired/excluded coverage) → blocked / rejected.
• Coding or clinical review needed (ICD discrepancy, high clinical risk) → under_review / clinical_review.
• Administrative only (secondary duplicate, already scheduled, shared-insurance verification, pending coverage, missing contact/address) → admin_followup / hold.
• Nothing pending → ready / approved. Purely administrative flags (shared insurance, primary-of-a-duplicate) may still be schedulable — a record can be ready/approved while carrying an issue code that is tracked for follow-up. Priority tiers: tier_1_immediate (urgent or time-critical, e.g. an appointment scheduled before clearance), tier_2_short_term (routine clinical follow-up), tier_3_administrative (admin cleanup). Map each code to its action/reason/blocker enum (see references/rule-cheatsheet.md).

Output & normalization conventions

• Emit JSON only — no prose, no trailing commentary.
• Include every required key; pin the constants the template fixes.
• Use only enum allowed_values; never invent status/code strings.
• Code arrays are unordered sets — de-duplicate; order is not graded but keep them clean.
• Order every list exactly as the template says (usually ascending by the record's id; alphabetical where stated; ranked where stated).
• IDs stay uppercase and verbatim as the portal shows them.
• Counts are integers, computed by iterating your rows; every enum key present (0 if none).
• Cross-check that per-record statuses and the summary counts reconcile before finishing.

Calibration note

The deterministic rules above (validity, network, duplicates, shared insurance, blockers, coding family, capacity, chart action) transfer directly. The policy details — exact risk/freshness thresholds, which contact owner/route a follow-up gets, and the precedence between hold and clinical_review — are portal-specific. Fix them from the template's enum lists and observed data, apply one consistent model across the whole cohort, and keep per-record status and summary counts internally consistent.