RCI — The Healthcare Knowledge Layer

The billing knowledge that prevents denials, accelerates payment, and eliminates guesswork across the revenue cycle

The problem

Healthcare billing is broken — and the root cause isn’t technology. It’s knowledge.

• 15-20% of claims are denied on first submission. Some providers see rates as high as 40%. The top reasons: coding errors, incomplete information, wrong billing form, missed filing deadlines. (MGMA, 2024)

• 17% of insured Americans had coverage denied for care recommended by their doctor. Nearly 6 in 10 said their care was delayed as a result. More than half didn’t challenge the denial — most didn’t know they could. (Commonwealth Fund, 2024)

• 35% of providers report staffing as their top RCM issue. Experienced billers and coders are retiring faster than they’re replaced. The knowledge walks out the door with them. (AAPC, 2025)

• 32-day average payment turnaround. Delayed reimbursements disrupt cash flow and strain provider-payer relationships. (Becker’s Healthcare, 2025)

Every one of these problems traces back to the same gap: someone didn’t know the right code, the right form, the right deadline, the right rule, or the right appeal process at the right time.

What RCI does

RCI is the knowledge layer for healthcare billing. It gives everyone in the revenue cycle — billers, providers, payers, clearinghouses, and the platforms that serve them — instant access to the billing rules, payment intelligence, and coding guidance they need to get claims right the first time.

Billers & Coders

Right code, right form, right deadline, right appeal. Before you submit and after you’re denied.

Providers & Clinical Staff

Medical necessity, prior auth, expected reimbursement — at the point of care, not after the denial.

Payers & Insurance

Validate coding, check necessity, benchmark payment — automate what your reviewers do manually.

Clearinghouses

Catch the errors that cause denials before the claim reaches the payer. Reduce rejections, not just route transactions.

EHR & Platform Builders

Embed billing knowledge into your product. Replace internal rule engines with a single API.

Which API to use

Client lookups for policy, 340B, prior auth, payment, and agents.

How RCI maps to the top billing challenges

Industry challenge	Denial rate impact	How RCI solves it
Coding errors — wrong CPT, missing modifiers, incorrect code for setting	30-40% of denials	AI code research agent + L5 service group rules + L3 modifier requirements
Wrong billing form — CMS-1500 submitted for institutional facility, or vice versa	Immediate rejection	L2 facility type → determines CMS-1500 vs UB-04 automatically
Missed filing deadlines — claim submitted past payer’s timely filing limit	Unrecoverable denial	L4 payer rules → filing deadline per payer (Medicare: 12 months, commercial: varies)
Missing prior authorization — procedure performed without required pre-auth	CARC 197 denial	L4 payer rules → prior auth requirements flagged before the service is performed
Medical necessity denials — payer says procedure wasn’t justified	~10% of denials	Medical necessity agent → validates against NCD/LCD criteria with clinical context
Incorrect place of service — POS code doesn’t match facility/setting	CARC 182 denial	L3 care setting → resolves POS code from facility type + care setting
Appeal knowledge gaps — provider doesn’t know deadline, level, or strategy	Denial becomes write-off	L4 payer rules → appeal levels + deadlines; denial resolution agent → strategy
Payment estimation gaps — no visibility into expected reimbursement	Under-billing, surprise balances	L6 service → RVU × GPCI × conversion factor = expected Medicare payment
Staff knowledge loss — experienced billers retire, rules aren’t documented	Systemic error increase	The entire L1-L6 knowledge graph captures institutional billing knowledge as API

The knowledge graph

RCI resolves billing context through six layers. Each builds on the previous — from geography to the specific dollar amount.

CCN "170001"
  │
  ├─ L1  Location      Kansas → GPCI values, MAC, Medicaid program
  ├─ L2  Facility      Short-term Hospital → payment system, billing form, TOB
  ├─ L3  Setting       Outpatient → place of service, modifiers, rate type
  ├─ L4  Payer         Medicare → 12-month filing, 5 appeal levels, prior auth
  ├─ L5  Service Group CPT 99213 → E/M rules, documentation requirements
  └─ L6  Service       99213 → RVU=2.22, GPCI-adjusted → Payment = $71.91

One API call. Six layers. The complete billing context.

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": "99213",
    "payer": "Medicare",
    "care_setting": "outpatient"
  }'

Free tools — no account required

Like Stedi built public EDI tools, RCI builds public billing knowledge tools. Browse, search, and use — free.

Knowledge Network

Searchable directory of payer rules, filing deadlines, appeal processes, and GPCI values.

Payment Calculator

Enter a CCN + CPT → see the full RVU/GPCI breakdown and expected Medicare payment.

Denial Inspector

Paste CARC/RARC codes → get plain-English explanation and appeal strategy.

Billing Rules Network

Open catalog of TOB codes, POS codes, modifiers, NCCI edits, and revenue codes.

CCN Resolver

Paste any CCN → see the complete L1-L6 billing context for that facility.

Rule Change Feed

Track payer rule changes, CMS updates, coding changes, and NCCI edits in real time.

Three ways to integrate

REST API

JSON API with full OpenAPI spec. Works with any language.

MCP Server

Connect AI agents (Claude, Cursor, custom) directly to the knowledge layer.

Webhooks

Get notified when agent jobs complete, rules change, or audit alerts fire.

What RCI is not

RCI is the knowledge layer, not the transaction layer. It doesn’t submit claims, check patient eligibility, or connect to payers. It tells you what to bill, how to bill it, and what to expect back. Use it alongside your clearinghouse, EHR, and payer connections.

RCI does	RCI does not
Determine the correct billing form	Submit claims to payers
Calculate expected Medicare payment	Process real-time eligibility checks
Resolve denial codes with appeal strategies	Transmit X12 EDI transactions
Validate medical necessity against NCD/LCD	Store patient health records
Provide coding guidance with AI agents	Replace your EHR or practice management system