Utilization Management
pa_t027_t027_o002_p01_nurse_review_payer
Nurse Clinical Review — Functional endoscopic sinus surgery — partial anterior ethmo
Provider faxed a letter of medical necessity overnight; case is at nurse review. Nurse clinical review queue for a 46-year-old female with Chronic maxillary sinusitis; Chronic ethmoidal sinusitis; Robert Chen MD requested Functional endoscopic sinus surgery — partial anterior ethmo. (Intake was recorded; triage routed the case.) Work the documentation review, record the recommendation, then carry the case through MD decision, any P2P, and finalize the determination yourself.
🧰 Workspace
| Resource | Location |
|---|---|
| Case data & payer tools | chi-bench MCP server |
| Handbook | /workspace/skills/managed-care-operations-handbook/SKILL.md |
| Incoming request docs | /logs/artifacts/workspaces/<case-id>/payer/incoming_request/ |
| Working files | /logs/artifacts/workspaces/<case-id>/payer/ |
| Shared handoff | /logs/artifacts/workspaces/<case-id>/shared/handoff/ |
| Tool reference | /opt/chi-bench-task-assets/tool_reference.md |
📋 Rules
- Use only payer namespaces:
payer_intake_hub,triage,review,determination,p2p,p2p_session,payer_letter_center - Do not inspect simulator source, tests, solution, or expectations files
- Do not fabricate source evidence — only create agent-authored summaries or correspondence when your workflow requires it
- Include rationale-rich notes when submitting clinical reviews