Payer system integration

Embed billing knowledge into claims adjudication, utilization review, and network management

RCI integrates with payer adjudication systems to provide coding validation, medical necessity assessment, and payment benchmarking.

Adjudication pipeline

Claim received (837P / 837I)
         │
    ┌────▼──────────────────────────────────┐
    │   Your Adjudication System            │
    │                                       │
    │   ┌───────────────────────────────┐   │
    │   │   RCI Knowledge Layer         │   │
    │   │                               │   │
    │   │   Validate facility type      │   │
    │   │   Validate coding             │   │
    │   │   Check medical necessity     │   │
    │   │   Calculate expected payment  │   │
    │   └───────────────────────────────┘   │
    │                                       │
    │   Clean → Auto-adjudicate             │
    │   Flagged → Queue for review          │
    │   Invalid → Deny with reason          │
    └───────────────────────────────────────┘

Use cases

Automated coding validation

Before adjudicating, verify the submitted CPT codes are appropriate for the facility type, care setting, and documented diagnoses:

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"
  }'

Check the L5 (Service Group) layer for documentation requirements and coding rules. Compare against what the provider submitted.

Medical necessity review

For high-cost procedures, pre-authorization requests, or flagged claims:

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": "Severe OA, failed conservative treatment 6 months."
  }'

RCI evaluates against NCD/LCD criteria and returns an assessment with confidence scores. All agent decisions are audited by SENTINEL for quality and security.

Payment benchmarking

Compare your contracted rates against MPFS-calculated expected payment:

curl -X POST https://api-dev.rcintell.com/v1/knowledge/payment-calc \
  -H "X-API-Key: kp_test_..." \
  -H "Content-Type: application/json" \
  -d '{"ccn": "170001", "cpt": "99214"}'

Use the GPCI-adjusted RVU calculation as a baseline for evaluating contracted provider rates across your network.

Network management

Use L1 (Location) data to understand geographic cost factors when building provider networks:

• GPCI values per area for fee schedule modeling
• MAC jurisdiction for claims processing routing
• HPSA designation for shortage area bonus calculations

Integration methods

Method	Best for	Latency
REST API	Batch adjudication, backend processing	Under 100ms per call
Webhooks	Async medical necessity results	Event-driven
MCP Server	AI-assisted utilization review tools	Real-time

Security and compliance

RCIntel is HIPAA compliant. Agent jobs include a reasoning trace. There is no separate audit-export API for integrators.