RCI for Providers & Clinical Staff

Medical necessity, prior auth, expected reimbursement, and coding context at the point of care

17% of insured Americans had coverage denied for care their doctor recommended. Nearly 6 in 10 said their care was delayed. More than half never challenged the denial — most didn’t even know they could. You’re making clinical decisions. RCI makes sure those decisions don’t hit a billing wall — before the patient leaves.

What RCI does for you

At the point of care

Situation	How RCI helps
Ordering a procedure	Check if the payer requires prior authorization before you order
Documenting the visit	Know the documentation requirements for the E/M level you’re billing
Explaining costs to a patient	Show expected reimbursement so the patient understands their financial responsibility
Checking medical necessity	Validate that the diagnosis supports the procedure before it’s performed

After the visit

Situation	How RCI helps
Claim denied for medical necessity	AI agent validates your clinical reasoning against NCD/LCD criteria and generates supporting documentation
Prior auth denial	Get the payer’s appeal process and deadlines, plus a recommended strategy
Coding questions	Your coders can use the code research agent to verify the CPT matches what was performed

Example: Pre-procedure check

A patient needs a total knee arthroplasty (CPT 27447) for severe osteoarthritis. Before scheduling:

Check medical necessity

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": "Is total knee arthroplasty medically necessary?",
    "cpt_code": "27447",
    "dx_codes": ["M17.11"],
    "clinical_notes": "Severe OA right knee. Failed 6 months PT, NSAIDs, 2 corticosteroid injections. Significant functional limitation.",
    "ccn": "170001"
  }'

RCI tells you:

• Assessment: Medically necessary
• Supporting LCD: L33728 — Total Knee Arthroplasty
• Criteria met: Failed conservative treatment ≥3 months, radiographic evidence
• Documentation checklist: What you need in the chart for the claim to be clean

Check prior auth and expected payment

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": "27447",
    "payer": "Cigna",
    "care_setting": "inpatient"
  }'

RCI tells you:

• Prior auth: Required for most commercial payers — check specific plan
• Expected payment: RVU-based estimate for this facility’s geography
• Filing deadline: 90-365 days (varies by contract)
• Appeal levels: Internal appeal → External review

What providers care about in each layer

Layer	Why it matters to you
L1 Location	Your facility’s GPCI affects how much the payer reimburses — this is why the same procedure pays differently in Manhattan vs rural Kansas
L3 Setting	Inpatient vs outpatient vs office changes the rate type and modifier requirements
L4 Payer	Prior auth rules vary dramatically by payer — Medicare rarely requires it, commercial payers almost always do for surgical procedures
L5 Service Group	Documentation requirements differ by procedure category — E/M visits need medical decision-making documentation, surgical procedures need operative reports
L6 Service	The actual expected payment, so you can have honest financial conversations with patients

Integrating with your workflow

RCI fits into your EHR workflow at key decision points:

Patient arrives → Check payer rules (L4: prior auth needed?)
    │
Provider orders procedure → Check medical necessity (agent)
    │
Procedure performed → Coding guidance (agent: correct CPT?)
    │
Claim submitted → Payment expectation (L6: expected $)
    │
If denied → Denial resolution (agent: appeal strategy)

Your EHR vendor can embed these calls directly. See the platform integration guide.

Related APIs

Need	Guide
Cited coverage policy	Payer policies
340B access	340B
Prior auth before the order	Prior authorization
Expected payment	Fee schedules