Northstar Payer Ops

Northstar Payer Ops

Workflow

1. Read the task prompt, task_context.json, and answer_template.json first.
2. Identify the target object, reporting date or period, and the exact output schema.
3. Pull only the records needed for that target from the shared payer-operations environment.
4. Derive values from returned facts and tables, not from memory.
5. Build the output with the exact keys, enums, ordering, rounding, and null-handling the template requires.

General Rules

• Return JSON only.
• Use exact field names from the template; do not add extras.
• Follow list ordering rules exactly.
• Use ISO dates and round monetary values to cents.
• Use null for absent modifiers or other nullable fields only when the schema allows it.
• Keep controlling records in basis_audit.controlling_record_ids and stale, excluded, or gap records in basis_audit.exception_record_ids.
• Order basis_audit.precedence_record_order from highest-priority controlling record to lower-priority exceptions.
• Use the schema's source_precedence rule to resolve conflicts between current, stale, and incomplete records.

Packet Families

Prior authorization / nurse review

• Review case, member, plan, request lines, clinical documents, policy criteria, and any authorization record.
• Map each required criterion to the schema's result enum.
• Include current evidence documents and excluded stale documents.
• Set recommendation, route, final status, letter type, next action, and authorization terms from the controlling records.

Appeal / assistance intake

• Review the appeal packet, medication failure evidence, drug trials or fills, and any assistance screen facts.
• Separate documented failures from undocumented or insufficient ones.
• Reflect required packet items, missing packet items, assistance status, and missing assistance fields exactly.
• Route standard, expedited, or assistance-only gaps to the next operational action.

Claim repricing / payment integrity

• Use the current benchmark schedule that matches payer, plan type, service domain, CPT, modifier, and effective date.
• Reject stale exports when a current schedule applies.
• For each line, compute correct allowed amount, line recovery amount, and total recovery in claim-line order.
• Use the current schedule source and version in the top-level packet.

Peer-to-peer closure

• Use the completed P2P event plus current clinical evidence and policy criteria.
• Decide whether the P2P changed the review.
• If adverse, supply the appeal deadline from the task rule and list unsupported PET factors or unresolved criteria.
• Set the recommended alternative modality only when the packet asks for one and the policy supports it.

Margin queue

• For each listed queue row, compute total_cost = variable_cost + fixed_cost_allocated.
• Compute margin = revenue - total_cost.
• Compute revenue_to_cost_ratio = revenue / total_cost.
• Mark rows below the threshold and rows flagged as charge sensitive separately.
• Identify the top below-threshold issue and the dollar gap to 120% of cost.

Final Check

• Verify the JSON parses.
• Verify enums, booleans, list order, and numeric precision against the template.
• Return only the JSON object.