> ## Documentation Index
> Fetch the complete documentation index at: https://docs.rcintell.com/llms.txt
> Use this file to discover all available pages before exploring further.

# RCI for Payers & Insurance

> Claims validation, coding verification, and adjudication intelligence

Claim denials create friction for everyone — providers rework, patients delay care, and your team spends time on appeals that could have been prevented. Nearly 2 in 5 people who challenge a bill get it reduced or eliminated, which means many denials shouldn't have happened in the first place. RCI gives your adjudication systems the billing rules and coding context to make accurate decisions faster — reducing preventable denials at the source.

## What RCI does for you

### Claims adjudication

| Task                           | How RCI helps                                                                            |
| ------------------------------ | ---------------------------------------------------------------------------------------- |
| **Validate billing form**      | Verify the provider used the correct form (CMS-1500 vs UB-04) for the facility type      |
| **Check place of service**     | Confirm the POS code matches the facility type and care setting                          |
| **Verify modifier usage**      | Check that modifiers are appropriate for the service and setting                         |
| **Validate coding**            | AI agent verifies CPT code matches the documented procedure                              |
| **Check medical necessity**    | AI agent evaluates whether the diagnosis supports the procedure against NCD/LCD criteria |
| **Calculate expected payment** | RVU × GPCI × CF gives you the expected Medicare payment for benchmarking                 |

### Provider network management

| Task                        | How RCI helps                                                       |
| --------------------------- | ------------------------------------------------------------------- |
| **Fee schedule validation** | Compare contracted rates against MPFS-calculated expected payments  |
| **Geographic adjustments**  | GPCI data by facility location for accurate geographic pricing      |
| **Facility classification** | CCN-based facility type verification (is this really a CAH? a SNF?) |

## Example: Automated claims review

A claim comes in for CPT 99214 at facility 170001, billed on a CMS-1500 with POS 22.

### Validate against knowledge

```bash theme={null}
curl -X POST https://api-dev.rcintell.com/v1/knowledge/resolve \
  -H "X-API-Key: kp_test_..." \
  -H "Content-Type: application/json" \
  -d '{
    "ccn": "170001",
    "cpt": "99214",
    "payer": "Medicare",
    "care_setting": "outpatient"
  }'
```

RCI returns the complete billing context. Your system can now automatically check:

| Claim field    | Expected (from RCI) | Claim value | Result              |
| -------------- | ------------------: | ----------- | ------------------- |
| Billing form   |            CMS-1500 | CMS-1500    | Pass                |
| POS code       |                  22 | 22          | Pass                |
| Payment system |                MPFS | —           | Benchmark: \$107.42 |
| Rate type      |            Facility | Facility    | Pass                |

### Validate medical necessity

When reviewing a claim for a high-cost procedure:

```bash theme={null}
curl -X POST https://api-dev.rcintell.com/v1/agents/medical-necessity \
  -H "X-API-Key: kp_test_..." \
  -H "Content-Type: application/json" \
  -d '{
    "query": "Does M17.11 support medical necessity for CPT 27447?",
    "cpt_code": "27447",
    "dx_codes": ["M17.11"],
    "clinical_notes": "Patient records indicate severe osteoarthritis with failed conservative treatment."
  }'
```

RCI's AI agent evaluates the claim against NCD/LCD criteria and returns an assessment with confidence scores — audited by SENTINEL.

## Adjudication pipeline integration

```
Claim received
    │
    ├─ RCI: Validate facility type (L2) — correct billing form?
    ├─ RCI: Validate care setting (L3) — correct POS code?
    ├─ RCI: Check payer rules (L4) — timely filing met?
    ├─ RCI: Verify coding (L5) — appropriate code for service group?
    ├─ RCI: Calculate expected payment (L6) — within fee schedule range?
    │
    ├─ If flagged → RCI: Medical necessity check (agent)
    │
    └─ Decision: Pay / Deny / Pend for review
```

## Bulk validation

For processing claims at scale, call the REST API directly with your pipeline. Each call resolves in milliseconds — no agent overhead for rule-based checks.

```python theme={null}
import httpx
import asyncio

async def validate_claim(client, claim):
    resp = await client.post("/v1/knowledge/resolve", json={
        "ccn": claim["facility_ccn"],
        "cpt": claim["cpt_code"],
        "payer": "Medicare",
        "care_setting": claim["care_setting"],
    })
    knowledge = resp.json()

    expected_form = knowledge["layers"][1]["data"].get("billing_form")
    expected_pos = knowledge["layers"][2]["data"].get("pos_code")

    errors = []
    if claim["billing_form"] != expected_form:
        errors.append(f"Wrong billing form: expected {expected_form}")
    if claim["pos_code"] != expected_pos:
        errors.append(f"Wrong POS: expected {expected_pos}")

    return {"claim_id": claim["id"], "errors": errors, "knowledge": knowledge}
```

## What payers care about in each layer

| Layer                | Adjudication value                                                                 |
| -------------------- | ---------------------------------------------------------------------------------- |
| **L1 Location**      | GPCI values for geographic payment calculation and fee schedule benchmarking       |
| **L2 Facility**      | Verify the facility type matches the billing form and payment system               |
| **L3 Setting**       | Confirm POS code and rate type (facility vs non-facility) are correct              |
| **L4 Payer**         | Your own rules reflected back — timely filing, appeal deadlines, prior auth        |
| **L5 Service Group** | Coding rules for the service category — documentation requirements, bundling rules |
| **L6 Service**       | MPFS-calculated expected payment as a benchmark against contracted rates           |