# Northstar Payer Ops > Structured JSON workflows for Northstar payer-operations tasks in the shared environment. Use when a prompt asks for an authorization summary, appeal and assistance disposition, claim repricing packet, peer-to-peer summary, or margin queue report that must be answered as one schema-valid JSON object. - Skill: `prism-shadow/northstar-payer-ops-5` (Agent Skill, multi-file: 2 files) - Install (CLI): `npx skillmds@latest add prism-shadow/northstar-payer-ops-5` - Raw SKILL.md: https://api.skillmd.com/api/skills/prism-shadow/northstar-payer-ops-5/raw - Safety review: pending - Works with: Claude Code, Claude.ai, OpenAI Codex - Category: AI & ML - Author: prism-shadow (https://skillmd.com/u/prism-shadow) - Updated: 2026-09-17 - Page: https://skillmd.com/skills/prism-shadow/northstar-payer-ops-5 --- # Northstar Payer Ops ## Workflow 1. Read the prompt, `input/payloads/task_context.json`, and `input/payloads/answer_template.json` first. 2. Identify the task family from the template keys. 3. Use the base URL and bearer token from the task context or prompt. 4. Query the live Northstar environment with `POST /sql/query`; use business endpoints when they expose the needed record directly. 5. Build the answer only from live records plus the task memo for scope and dates. Treat the memo as a locator, not as evidence. 6. Follow the template exactly. Preserve list order rules, enum spellings, number precision, and date formats. Emit one JSON object only. 7. Write `basis_audit` from the records that directly controlled the result. Put controlling records first, then gaps, stale records, or exclusions. ## Shared Rules - Prefer current clinical, appeal, or benchmark records over stale exports or old schedules. - Keep `null` for absent modifiers. - Use ISO dates (`YYYY-MM-DD`) and round currency to cents. - Keep ratios at the precision requested by the template. - When a task limits scope to explicit IDs or row IDs, ignore everything else. - Do not add narrative, markdown fences, or extra keys. - Use the environment endpoints listed in the task note when they are clearer than SQL: `GET /api/tables`, `GET /api/cases`, `GET /api/cases/{case_id}`, `GET /api/policies`, `GET /api/policies/{policy_id}`, `GET /api/documents/{document_id}`, `GET /api/rate-schedules`, and `GET /api/appeals`. ## Task Families ### Authorization summaries - Use when the template requires `case_id`, `recommendation`, `final_status`, `route`, `authorization`, `criteria_results`, `evidence_documents`, `excluded_documents`, `determination_letter`, and `next_action`. - Review the case, member and plan context, requested therapy lines, applicable policy criteria, clinical documents, and any authorization record. - Map outcomes consistently: approve when the required criteria and authorization support the request; pend when key information is missing; escalate to medical director or peer-to-peer when physician review is needed; deny when criteria fail; use partial approval when only part of the request is supportable. - Populate `criteria_results` for `PT-ACTIVE`, `PT-DEFICIT`, `PT-DX`, `PT-POC`, and `PT-UNITS`. - Include only controlling evidence documents in `evidence_documents`; list stale or noncontrolling case documents in `excluded_documents`. - Fill `authorization` with the auth number, approved units, approved date span, approved CPTs in ascending order, and the line modifier. - Set `source_precedence` to `current_clinical_records_over_stale_export`. ### Appeal and assistance intake - Use when the template requires `case_id`, `appeal_id`, `drug`, `appeal_path`, `expedited`, `appeal_deadline`, `owner`, medication failure lists, packet items, assistance, and next action. - Resolve the appeal first, then the assistance screen. Let appeal records control over assistance facts when they conflict. - Classify prior medication failures into `documented_failures` and `undocumented_or_insufficient_failures` using the evidence in the case. - Order packet items so appeal evidence appears before assistance items; list gaps in the same operational order. - Mark assistance `eligible_ready` only when the program is identified and no required fields are missing. - Set `source_precedence` to `payer_appeal_before_manufacturer_assistance`. ### Claim repricing - Use when the template requires `claim_id`, `case_id`, `auth_number`, benchmark fields, totals, line-level corrections, resubmission route, priority, and audit. - Select the benchmark by plan, modifier, and date. Reject stale exports and note the rejected source. - Keep claim lines in source claim order. - Compute `paid_total`, `correct_allowed_total`, and `recovery_amount` from the line items. Use cents precision. - Set each line disposition to `correct_upward`, `correct_downward`, `no_change`, or `deny_line` based on the corrected allowed amount. - Set `source_precedence` to `effective_benchmark_by_plan_modifier_and_date`. ### Peer-to-peer summaries - Use when the template requires `case_id`, `p2p_id`, `requested_cpt`, `p2p_outcome`, `final_status`, PET criteria, unresolved criteria, missing PET factors, `letter_type`, `recommended_alternative`, and `internal_appeal_deadline`. - Decide whether the P2P added new patient-specific information that materially changed the review. - Map `criteria_results` to `PET-IND` and `PET-FACTOR`. - List only unresolved criteria in `unresolved_criteria`. - When the final result is adverse, calculate the internal appeal deadline from the final adverse determination date using the plan window in the task memo. - Set `source_precedence` to `new_patient_specific_p2p_information`. ### Margin queue summaries - Use when the template requires `case_id`, `period`, threshold ratio, row summaries, segment lists, top issue, gap, and audit. - Review only the row IDs listed in the task memo. - Compute each row's ratio from the underlying revenue and cost figures, then flag `below_threshold` at the requested cutoff. - Flag `charge_sensitive` from the queue facts, keep row order aligned with the supplied row IDs, and sort the segment summary lists alphabetically. - Set `top_issue` to the worst below-threshold segment/CPT pair and compute `gap_to_120pct` against 120 percent of cost. - Set `source_precedence` to `margin_threshold_then_charge_sensitivity`. ## Audit Format - Put the directly controlling record IDs in `controlling_record_ids`. - Put missing, stale, exception, or excluded records in `exception_record_ids`. - List the combined record trail in `precedence_record_order`, highest priority first.