> ## 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.

# Catalog denial packet (coverage + NCCI + PA + payment + policy + CARC)

> Assemble a denial packet from the catalog in one call.

LCD/NCD coverage, NCCI, prior auth, expected allowed, cited policy,
X12 CARC plus payer playbook, and timely-filing / appeal windows.
Does not invoke the LLM denial-resolution agent. Trial keys may call
this path (``/v1/encounter/`` is on the trial allowlist).



## OpenAPI

````yaml /docs/openapi.client.json post /v1/encounter/denial-check
openapi: 3.1.0
info:
  description: >-
    Client API for RCIntel. Authenticate with X-API-Key. See Guides → Which API
    to use.
  summary: Multi-tenant knowledge API for healthcare revenue cycle management.
  title: Healthcare Knowledge Layer
  version: 0.1.0
servers: []
security: []
tags:
  - description: >-
      Cited payer policy lookup — GET /v1/policies and GET /v1/policies/changes.
      Medicare FFS returns NCDs/LCDs/MACs; commercial payers return that payer's
      documents only. Query payer, code, state, plan_type.
    name: policies
  - description: >-
      Payer-policy PDF parse and retrieve for Workspace / Payer Knowledge.
      Service-authenticated (X-Admin-Secret); chunks stored in Postgres.
    name: policy
  - description: >-
      Manufacturer 340B contract-pharmacy policy, fail-closed access, and the
      change feed. Different API from GET /v1/policies.
    name: 340B Policy
  - description: CRD-style prior authorization check, documentation, and vendors.
    name: prior-auth
  - description: Public payer directory (no API key on list/detail).
    name: payers-public
  - description: >-
      Payer network directory — search payers, check prior auth requirements,
      view filing rules, denial patterns, and appeal levels.
    name: payers
  - description: >-
      Resolve healthcare billing knowledge across the L1-L6 layer stack.
      Includes payment calculation, billing guidance, and per-layer queries.
    name: knowledge
  - description: >-
      CMS Fee Schedule lookups — OPPS (Addendum B / APC), DMEPOS (state-level
      pricing), and Clinical Lab Fee Schedule (CLFS).
    name: fee-schedules
  - description: >-
      NCCI (National Correct Coding Initiative) — dedicated MUE limits, PTP
      bundling edits, add-on code edits, and code pair validation. Medicare
      edits under /ncci/*, the separate CMS Medicaid edit set under
      /ncci/medicaid/*.
    name: ncci
  - description: >-
      Service code intelligence — CPT/HCPCS lookup, RVU data, NCCI edits,
      payment calculation, implant/GUDID search, and service group
      classification.
    name: codes
  - description: >-
      Submit asynchronous AI agent jobs for code research, medical necessity,
      and denial resolution. Poll for results and retrieve reasoning traces.
    name: agents
  - description: >-
      Register and manage healthcare facilities by CCN (Medicare Provider
      Number). Each facility is the root entity for knowledge resolution.
    name: facilities
  - description: >-
      NPI Registry — live search against CMS NPPES API for provider and
      organization National Provider Identifiers.
    name: npi
  - description: >-
      OpenFDA drug product lookup by NDC. Includes product-level fields with
      normalized ingredient and package detail.
    name: drugs
  - name: encounter
  - name: mcp
  - description: Health checks, service metadata, and Prometheus metrics.
    name: system
paths:
  /v1/encounter/denial-check:
    post:
      tags:
        - encounter
      summary: Catalog denial packet (coverage + NCCI + PA + payment + policy + CARC)
      description: |-
        Assemble a denial packet from the catalog in one call.

        LCD/NCD coverage, NCCI, prior auth, expected allowed, cited policy,
        X12 CARC plus payer playbook, and timely-filing / appeal windows.
        Does not invoke the LLM denial-resolution agent. Trial keys may call
        this path (``/v1/encounter/`` is on the trial allowlist).
      operationId: check_denial_v1_encounter_denial_check_post
      requestBody:
        content:
          application/json:
            schema:
              $ref: '#/components/schemas/DenialCheckRequest'
        required: true
      responses:
        '200':
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/DenialCheckResponse'
          description: Successful Response
        '422':
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/HTTPValidationError'
          description: Validation Error
      security:
        - APIKeyHeader: []
components:
  schemas:
    DenialCheckRequest:
      description: >-
        Post-adjudication denial packet: coverage + NCCI + PA + payment + policy
        + CARC + filing.


        One call so a trial key can assemble the packet without burning the
        daily

        quota on six round trips. Does not run the LLM denial-resolution agent.
      properties:
        carc:
          anyOf:
            - type: string
            - type: 'null'
          description: Claim Adjustment Reason Code (CO-197, 197, 4)
          title: Carc
        claim_type:
          default: professional
          description: professional or institutional
          title: Claim Type
          type: string
        date_of_service:
          anyOf:
            - type: string
            - type: 'null'
          description: Date of service (YYYY-MM-DD)
          title: Date Of Service
        dx:
          description: Claim-level DX; used for institutional claims and lines with no DX
          items:
            $ref: '#/components/schemas/EncounterDiagnosis'
          title: Dx
          type: array
        lines:
          description: Denied procedure lines (CPT + DX + optional modifiers)
          items:
            $ref: '#/components/schemas/EncounterCoverageLine'
          maxItems: 25
          minItems: 1
          title: Lines
          type: array
        locality:
          anyOf:
            - type: string
            - type: 'null'
          description: GPCI locality for payment estimates
          title: Locality
        payer_slug:
          description: Payer slug or alias (e.g. uhc, medicare_ffs)
          title: Payer Slug
          type: string
        plan_type:
          anyOf:
            - type: string
            - type: 'null'
          description: commercial, medicare_advantage, medicaid, ffs
          title: Plan Type
        rarc:
          anyOf:
            - type: string
            - type: 'null'
          description: Remittance Advice Remark Code
          title: Rarc
        state:
          anyOf:
            - type: string
            - type: 'null'
          description: 2-letter state for LCD MAC + filing overrides
          title: State
      required:
        - payer_slug
        - lines
      title: DenialCheckRequest
      type: object
    DenialCheckResponse:
      description: Catalog denial packet. Not an LLM appeal letter.
      properties:
        appeal_deadlines:
          anyOf:
            - $ref: '#/components/schemas/AppealDeadlineResponse'
            - type: 'null'
        appeal_rules:
          items:
            $ref: '#/components/schemas/AppealRuleResponse'
          title: Appeal Rules
          type: array
        carc:
          anyOf:
            - type: string
            - type: 'null'
          title: Carc
        codes:
          items:
            type: string
          title: Codes
          type: array
        coverage:
          items:
            $ref: '#/components/schemas/EncounterCoverageResult'
          title: Coverage
          type: array
        coverage_clean:
          default: true
          title: Coverage Clean
          type: boolean
        date_of_service:
          anyOf:
            - type: string
            - type: 'null'
          title: Date Of Service
        denial:
          anyOf:
            - $ref: '#/components/schemas/DenialCodeLookupResponse'
            - type: 'null'
        filing_status:
          anyOf:
            - $ref: '#/components/schemas/ClaimFilingStatus'
            - type: 'null'
        ncci_clean:
          default: true
          title: Ncci Clean
          type: boolean
        ncci_conflicts:
          items:
            $ref: '#/components/schemas/NCCIBatchConflict'
          title: Ncci Conflicts
          type: array
        pa_required_count:
          default: 0
          title: Pa Required Count
          type: integer
        pa_results:
          items:
            $ref: '#/components/schemas/EncounterPAResult'
          title: Pa Results
          type: array
        packet_ready:
          description: >-
            True when coverage has no blocker, NCCI is clean, and timely filing
            has not expired. PA-required is a warning, not a blocker.
          title: Packet Ready
          type: boolean
        payer_name:
          anyOf:
            - type: string
            - type: 'null'
          title: Payer Name
        payer_slug:
          title: Payer Slug
          type: string
        payment_estimates:
          items:
            $ref: '#/components/schemas/EncounterPaymentEstimate'
          title: Payment Estimates
          type: array
        policies:
          items:
            $ref: '#/components/schemas/DenialPolicyHit'
          title: Policies
          type: array
        rarc:
          anyOf:
            - type: string
            - type: 'null'
          title: Rarc
        state:
          anyOf:
            - type: string
            - type: 'null'
          title: State
        total_estimated_payment:
          default: 0
          title: Total Estimated Payment
          type: number
        warnings:
          items:
            $ref: '#/components/schemas/EncounterWarning'
          title: Warnings
          type: array
      required:
        - payer_slug
        - codes
        - packet_ready
      title: DenialCheckResponse
      type: object
    HTTPValidationError:
      properties:
        detail:
          items:
            $ref: '#/components/schemas/ValidationError'
          title: Detail
          type: array
      title: HTTPValidationError
      type: object
    EncounterDiagnosis:
      description: >-
        One diagnosis with its 837 loop 2300 HI qualifier (primary vs
        secondary).
      properties:
        code:
          description: ICD-10-CM diagnosis code
          title: Code
          type: string
        qualifier:
          default: ABF
          description: >-
            837 HI qualifier: ABK=principal/primary, ABF=secondary,
            ABJ=admitting, APR=reason for visit, ABN=external cause. Accepts
            'primary'/'secondary' aliases.
          title: Qualifier
          type: string
      required:
        - code
      title: EncounterDiagnosis
      type: object
    EncounterCoverageLine:
      description: >-
        One charge line: a procedure code with its linked diagnoses
        (professional).
      properties:
        code:
          description: >-
            CPT/HCPCS procedure code; inline modifiers (99213-25) are split into
            modifiers
          title: Code
          type: string
        dx:
          description: ICD-10 diagnoses linked to this line (professional claims)
          items:
            $ref: '#/components/schemas/EncounterDiagnosis'
          title: Dx
          type: array
        line_id:
          anyOf:
            - type: string
            - type: 'null'
          description: Caller line identifier, echoed back
          title: Line Id
        modifiers:
          description: Line modifiers (e.g. ['RT']). Coverage is matched on the bare code.
          items:
            type: string
          title: Modifiers
          type: array
      required:
        - code
      title: EncounterCoverageLine
      type: object
    AppealDeadlineResponse:
      description: Appeal deadline calculation for a payer given a denial date.
      properties:
        appeal_levels:
          items:
            $ref: '#/components/schemas/AppealLevelDeadline'
          title: Appeal Levels
          type: array
        denial_date:
          title: Denial Date
          type: string
        notice_text:
          anyOf:
            - type: string
            - type: 'null'
          description: Catalog-level notice when state was omitted.
          title: Notice Text
        payer_name:
          title: Payer Name
          type: string
        payer_slug:
          title: Payer Slug
          type: string
        posted_states:
          description: USPS states with a posted Community Plan appeal row.
          items:
            type: string
          title: Posted States
          type: array
        state_filter:
          anyOf:
            - type: string
            - type: 'null'
          description: USPS state you passed.
          title: State Filter
        state_required:
          default: false
          description: >-
            True when Community Plan appeal rows exist and you did not pass
            state.
          title: State Required
          type: boolean
      required:
        - payer_slug
        - payer_name
        - denial_date
      title: AppealDeadlineResponse
      type: object
    AppealRuleResponse:
      properties:
        appeal_level:
          title: Appeal Level
          type: integer
        audience:
          anyOf:
            - type: string
            - type: 'null'
          title: Audience
        citation:
          anyOf:
            - type: string
            - type: 'null'
          title: Citation
        deadline_days:
          anyOf:
            - type: integer
            - type: 'null'
          description: >-
            Posted appeal window in days. Null when the source has no universal
            number.
          title: Deadline Days
        external_review_deadline_days:
          anyOf:
            - type: integer
            - type: 'null'
          title: External Review Deadline Days
        geo_scope:
          anyOf:
            - type: string
            - type: 'null'
          description: national or state. Community Plan is always state.
          title: Geo Scope
        level_name:
          anyOf:
            - type: string
            - type: 'null'
          title: Level Name
        notice_text:
          anyOf:
            - type: string
            - type: 'null'
          description: Posted source language
          title: Notice Text
        peer_to_peer_available:
          default: false
          title: Peer To Peer Available
          type: boolean
        product_line:
          anyOf:
            - type: string
            - type: 'null'
          title: Product Line
        required_documents:
          items:
            type: string
          title: Required Documents
          type: array
        scope_label:
          anyOf:
            - type: string
            - type: 'null'
          title: Scope Label
        source_url:
          anyOf:
            - type: string
            - type: 'null'
          title: Source Url
        state:
          anyOf:
            - type: string
            - type: 'null'
          description: >-
            USPS state for a Community Plan row. Null means national, not
            unspecified.
          title: State
        state_specific_rules:
          additionalProperties: true
          title: State Specific Rules
          type: object
        submission_method:
          anyOf:
            - type: string
            - type: 'null'
          title: Submission Method
        success_rate:
          anyOf:
            - type: number
            - type: 'null'
          description: Not served. YAML success_rate is not a posted fact.
          title: Success Rate
      required:
        - appeal_level
      title: AppealRuleResponse
      type: object
    EncounterCoverageResult:
      description: >-
        Coverage verdict for one line (professional) or one code
        (institutional).
      properties:
        code:
          title: Code
          type: string
        coverage_status:
          anyOf:
            - type: string
            - type: 'null'
          description: >-
            covered, dx_not_on_lcd, dx_required, not_covered, conditional, or
            null
          title: Coverage Status
        dx_required:
          default: false
          title: Dx Required
          type: boolean
        geo_scope:
          anyOf:
            - type: string
            - type: 'null'
          description: national (NCD) or mac_jurisdiction (LCD)
          title: Geo Scope
        lcd_id:
          anyOf:
            - type: string
            - type: 'null'
          title: Lcd Id
        line_id:
          anyOf:
            - type: string
            - type: 'null'
          title: Line Id
        matched_dx:
          items:
            type: string
          title: Matched Dx
          type: array
        ncd_id:
          anyOf:
            - type: string
            - type: 'null'
          title: Ncd Id
        payer_overlay:
          anyOf:
            - $ref: '#/components/schemas/PayerCoverageOverlay'
            - type: 'null'
          description: >-
            Posted commercial policy for this code. Null on Medicare-only
            checks. coverage_status is set only for an explicit cover/deny
            action.
        policy_title:
          anyOf:
            - type: string
            - type: 'null'
          title: Policy Title
        primary_covered:
          default: false
          description: True when the principal diagnosis is on the covered list
          title: Primary Covered
          type: boolean
        primary_dx:
          anyOf:
            - type: string
            - type: 'null'
          description: The principal (ABK) diagnosis evaluated
          title: Primary Dx
        source:
          anyOf:
            - type: string
            - type: 'null'
          description: Which policy drove the verdict, e.g. medicare_lcd
          title: Source
        source_url:
          anyOf:
            - type: string
            - type: 'null'
          title: Source Url
      required:
        - code
      title: EncounterCoverageResult
      type: object
    DenialCodeLookupResponse:
      description: Denial code resolution across one or all payers.
      properties:
        denial_code:
          title: Denial Code
          type: string
        payer_count:
          default: 0
          description: Number of payers with data for this code
          title: Payer Count
          type: integer
        reliability:
          $ref: '#/components/schemas/ReliabilityMetadata'
          description: User-visible reliability metadata for denial lookup resolution.
        results:
          items:
            $ref: '#/components/schemas/DenialPatternResponse'
          title: Results
          type: array
        total_results:
          default: 0
          title: Total Results
          type: integer
        x12_master:
          description: X12 master CARC metadata from the pipeline-backed catalog.
          items:
            $ref: '#/components/schemas/X12MasterDenialResponse'
          title: X12 Master
          type: array
      required:
        - denial_code
      title: DenialCodeLookupResponse
      type: object
    ClaimFilingStatus:
      description: Timely filing status for the claim.
      properties:
        claim_type:
          title: Claim Type
          type: string
        days_remaining:
          title: Days Remaining
          type: integer
        deadline_date:
          title: Deadline Date
          type: string
        effective_days:
          title: Effective Days
          type: integer
        is_expired:
          title: Is Expired
          type: boolean
        override_applied:
          anyOf:
            - type: string
            - type: 'null'
          title: Override Applied
        standard_days:
          title: Standard Days
          type: integer
      required:
        - claim_type
        - standard_days
        - effective_days
        - deadline_date
        - days_remaining
        - is_expired
      title: ClaimFilingStatus
      type: object
    NCCIBatchConflict:
      description: >-
        A bundled pair found within the batch; ``status`` says whether it still
        conflicts.
      properties:
        bypass_modifier:
          anyOf:
            - type: string
            - type: 'null'
          description: The PTP-associated modifier that bypasses the edit (e.g. 25, 59, XU)
          title: Bypass Modifier
        claim_type:
          anyOf:
            - type: string
            - type: 'null'
          title: Claim Type
        code1:
          title: Code1
          type: string
        code1_modifiers:
          items:
            type: string
          title: Code1 Modifiers
          type: array
        code2:
          title: Code2
          type: string
        code2_modifiers:
          items:
            type: string
          title: Code2 Modifiers
          type: array
        col1_proc_cd:
          anyOf:
            - type: string
            - type: 'null'
          title: Col1 Proc Cd
        col2_proc_cd:
          anyOf:
            - type: string
            - type: 'null'
          title: Col2 Proc Cd
        edit_scope:
          anyOf:
            - type: string
            - type: 'null'
          title: Edit Scope
        effective_date:
          anyOf:
            - type: string
            - type: 'null'
          title: Effective Date
        is_bundled:
          default: true
          title: Is Bundled
          type: boolean
        modifier_allowed:
          anyOf:
            - type: boolean
            - type: 'null'
          title: Modifier Allowed
        modifier_indicator:
          anyOf:
            - type: string
            - type: 'null'
          title: Modifier Indicator
        'on':
          anyOf:
            - enum:
                - column_one
                - column_two
              type: string
            - type: 'null'
          description: >-
            Which code of the edit carried bypass_modifier: column_one or
            column_two
          title: 'On'
        payer:
          anyOf:
            - type: string
            - type: 'null'
          title: Payer
        program:
          anyOf:
            - type: string
            - type: 'null'
          title: Program
        ptp_rationale:
          anyOf:
            - type: string
            - type: 'null'
          title: Ptp Rationale
        state:
          anyOf:
            - type: string
            - type: 'null'
          title: State
        status:
          anyOf:
            - enum:
                - conflict
                - allowed_with_modifier
                - not_applicable
              type: string
            - type: 'null'
          description: >-
            conflict | allowed_with_modifier | not_applicable.
            allowed_with_modifier = indicator 1 and a PTP-associated modifier on
            either code. Null when the pair has no edit.
          title: Status
      required:
        - code1
        - code2
      title: NCCIBatchConflict
      type: object
    EncounterPAResult:
      description: PA determination for a single code in the encounter.
      properties:
        auth_type:
          anyOf:
            - type: string
            - type: 'null'
          title: Auth Type
        authorization_on_claim:
          anyOf:
            - type: boolean
            - type: 'null'
          description: 'Claim check only: an authorization number was supplied for this code'
          title: Authorization On Claim
        code:
          title: Code
          type: string
        confidence:
          title: Confidence
          type: number
        delegation_vendor:
          anyOf:
            - type: string
            - type: 'null'
          title: Delegation Vendor
        determination:
          title: Determination
          type: string
        pa_required:
          title: Pa Required
          type: boolean
        pa_threshold:
          anyOf:
            - type: integer
            - type: 'null'
          title: Pa Threshold
        policy_documents:
          anyOf:
            - items:
                $ref: '#/components/schemas/PolicyDocumentResult'
              type: array
            - type: 'null'
          description: What each requested payer policy document requires for this code
          title: Policy Documents
        required_documents:
          items:
            type: string
          title: Required Documents
          type: array
        resolution_tier:
          title: Resolution Tier
          type: string
        threshold_remaining:
          anyOf:
            - type: integer
            - type: 'null'
          title: Threshold Remaining
      required:
        - code
        - pa_required
        - determination
        - confidence
        - resolution_tier
      title: EncounterPAResult
      type: object
    EncounterPaymentEstimate:
      description: |-
        Medicare MPFS expected allowed for a single code.

        This is never a commercial contracted allowed. A remit / 835 is required
        for the payer's paid amount.
      properties:
        code:
          title: Code
          type: string
        conversion_factor:
          title: Conversion Factor
          type: number
        estimated_payment:
          title: Estimated Payment
          type: number
        facility_rate:
          default: true
          title: Facility Rate
          type: boolean
        locality:
          default: '0000'
          title: Locality
          type: string
        locality_name:
          anyOf:
            - type: string
            - type: 'null'
          title: Locality Name
        locality_source:
          anyOf:
            - type: string
            - type: 'null'
          description: >-
            caller (explicit GPCI locality), rest_of_state (from state), or
            unadjusted
          title: Locality Source
        missing_rvu:
          default: false
          description: >-
            True when no MPFS RVU was found; estimated_payment 0.00 is not an
            allowed amount
          title: Missing Rvu
          type: boolean
        mp_rvu_adjusted:
          title: Mp Rvu Adjusted
          type: number
        pe_rvu_adjusted:
          title: Pe Rvu Adjusted
          type: number
        schedule:
          default: medicare_mpfs
          description: Always Medicare MPFS. Not a commercial contracted allowed.
          title: Schedule
          type: string
        work_rvu_adjusted:
          title: Work Rvu Adjusted
          type: number
      required:
        - code
        - estimated_payment
        - work_rvu_adjusted
        - pe_rvu_adjusted
        - mp_rvu_adjusted
        - conversion_factor
      title: EncounterPaymentEstimate
      type: object
    DenialPolicyHit:
      description: One cited policy document for a denied line's code.
      properties:
        action:
          anyOf:
            - type: string
            - type: 'null'
          title: Action
        code:
          title: Code
          type: string
        coverage_status:
          anyOf:
            - type: string
            - type: 'null'
          title: Coverage Status
        doc_id:
          anyOf:
            - type: string
            - type: 'null'
          title: Doc Id
        document_kind:
          anyOf:
            - type: string
            - type: 'null'
          title: Document Kind
        payer_slug:
          anyOf:
            - type: string
            - type: 'null'
          title: Payer Slug
        pdf_uri:
          anyOf:
            - type: string
            - type: 'null'
          title: Pdf Uri
        title:
          anyOf:
            - type: string
            - type: 'null'
          title: Title
      required:
        - code
      title: DenialPolicyHit
      type: object
    EncounterWarning:
      description: A warning or advisory generated during encounter analysis.
      properties:
        code:
          anyOf:
            - type: string
            - type: 'null'
          title: Code
        message:
          title: Message
          type: string
        severity:
          description: info, warning, or critical
          title: Severity
          type: string
      required:
        - severity
        - message
      title: EncounterWarning
      type: object
    ValidationError:
      properties:
        ctx:
          title: Context
          type: object
        input:
          title: Input
        loc:
          items:
            anyOf:
              - type: string
              - type: integer
          title: Location
          type: array
        msg:
          title: Message
          type: string
        type:
          title: Error Type
          type: string
      required:
        - loc
        - msg
        - type
      title: ValidationError
      type: object
    AppealLevelDeadline:
      description: Computed appeal deadline for a single appeal level.
      properties:
        appeal_level:
          title: Appeal Level
          type: integer
        citation:
          anyOf:
            - type: string
            - type: 'null'
          title: Citation
        days_remaining:
          anyOf:
            - type: integer
            - type: 'null'
          description: Days until deadline (negative if expired)
          title: Days Remaining
        deadline_date:
          anyOf:
            - type: string
            - type: 'null'
          description: Appeal deadline date (YYYY-MM-DD)
          title: Deadline Date
        deadline_days:
          anyOf:
            - type: integer
            - type: 'null'
          title: Deadline Days
        external_review_deadline_days:
          anyOf:
            - type: integer
            - type: 'null'
          title: External Review Deadline Days
        geo_scope:
          anyOf:
            - type: string
            - type: 'null'
          description: national or state. Community Plan is always state.
          title: Geo Scope
        is_expired:
          anyOf:
            - type: boolean
            - type: 'null'
          title: Is Expired
        level_name:
          anyOf:
            - type: string
            - type: 'null'
          title: Level Name
        notice_text:
          anyOf:
            - type: string
            - type: 'null'
          title: Notice Text
        peer_to_peer_available:
          default: false
          title: Peer To Peer Available
          type: boolean
        product_line:
          anyOf:
            - type: string
            - type: 'null'
          title: Product Line
        required_documents:
          items:
            type: string
          title: Required Documents
          type: array
        scope_label:
          anyOf:
            - type: string
            - type: 'null'
          title: Scope Label
        source_url:
          anyOf:
            - type: string
            - type: 'null'
          title: Source Url
        state:
          anyOf:
            - type: string
            - type: 'null'
          description: >-
            USPS state on this Community Plan row. Null on national rows is not
            a missing filter.
          title: State
        submission_method:
          anyOf:
            - type: string
            - type: 'null'
          title: Submission Method
        success_rate:
          anyOf:
            - type: number
            - type: 'null'
          description: Not served. YAML success_rate is not a posted fact.
          title: Success Rate
      required:
        - appeal_level
      title: AppealLevelDeadline
      type: object
    PayerCoverageOverlay:
      description: Posted commercial policy attached to a Medicare coverage row.
      properties:
        action:
          anyOf:
            - type: string
            - type: 'null'
          description: >-
            Posted action as stored. Reimbursement/mention language is not a
            coverage verdict.
          title: Action
        applied:
          default: true
          title: Applied
          type: boolean
        coverage_status:
          anyOf:
            - type: string
            - type: 'null'
          description: >-
            Set only when action/status is covered, not_covered, or
            may_not_be_covered
          title: Coverage Status
        doc_id:
          anyOf:
            - type: string
            - type: 'null'
          title: Doc Id
        geo_scope:
          anyOf:
            - type: string
            - type: 'null'
          title: Geo Scope
        kind:
          anyOf:
            - type: string
            - type: 'null'
          title: Kind
        payer_slug:
          title: Payer Slug
          type: string
        source:
          default: mart_payer_policy
          description: Catalog table the overlay was read from
          title: Source
          type: string
        title:
          anyOf:
            - type: string
            - type: 'null'
          title: Title
      required:
        - payer_slug
      title: PayerCoverageOverlay
      type: object
    ReliabilityMetadata:
      description: User-visible reliability metadata attached to API responses.
      properties:
        data_sources:
          additionalProperties:
            type: string
          description: Data-source backends used to build this response.
          title: Data Sources
          type: object
        dataset_versions:
          additionalProperties:
            type: string
          description: >-
            CMS/DHCS/NLM/FDA named versions used to compose this response (e.g.
            mpfs=CY2026, ipps=FY2026). See GET /v1/data/changes.
          title: Dataset Versions
          type: object
        degraded:
          default: false
          description: True when a fallback or non-primary source path was used.
          title: Degraded
          type: boolean
        generated_at:
          description: UTC timestamp when the response payload was composed.
          title: Generated At
          type: string
        warnings:
          description: Human-readable caveats relevant to downstream consumers.
          items:
            type: string
          title: Warnings
          type: array
      required:
        - generated_at
      title: ReliabilityMetadata
      type: object
    DenialPatternResponse:
      properties:
        auto_appealable:
          default: false
          title: Auto Appealable
          type: boolean
        avg_resolution_days:
          anyOf:
            - type: integer
            - type: 'null'
          title: Avg Resolution Days
        denial_category:
          anyOf:
            - type: string
            - type: 'null'
          title: Denial Category
        denial_code:
          anyOf:
            - type: string
            - type: 'null'
          title: Denial Code
        documentation_needed:
          items:
            type: string
          title: Documentation Needed
          type: array
        frequency_rank:
          anyOf:
            - type: integer
            - type: 'null'
          title: Frequency Rank
        remark_code:
          anyOf:
            - type: string
            - type: 'null'
          title: Remark Code
        resolution_steps:
          items:
            type: string
          title: Resolution Steps
          type: array
        root_cause:
          anyOf:
            - type: string
            - type: 'null'
          title: Root Cause
        source:
          anyOf:
            - type: string
            - type: 'null'
          description: >-
            payer_playbook = YAML root_cause/steps for this payer. x12_master =
            published CARC catalog text only; not a payer-specific root cause.
          title: Source
        success_rate:
          anyOf:
            - type: number
            - type: 'null'
          title: Success Rate
        x12_master:
          description: >-
            X12 CARC catalog rows for this playbook code. Playbook (root_cause /
            resolution_steps) stays payer-specific; this is the published CARC
            text, not a substitute for it.
          items:
            $ref: '#/components/schemas/X12MasterDenialResponse'
          title: X12 Master
          type: array
      title: DenialPatternResponse
      type: object
    X12MasterDenialResponse:
      description: X12 master catalog row for a CARC denial code.
      properties:
        carc_code:
          title: Carc Code
          type: string
        carc_description:
          title: Carc Description
          type: string
        effective_date:
          anyOf:
            - type: string
            - type: 'null'
          title: Effective Date
        group_code:
          anyOf:
            - type: string
            - type: 'null'
          title: Group Code
        group_description:
          anyOf:
            - type: string
            - type: 'null'
          title: Group Description
        last_modified:
          anyOf:
            - type: string
            - type: 'null'
          title: Last Modified
        notes:
          anyOf:
            - type: string
            - type: 'null'
          title: Notes
      required:
        - carc_code
        - carc_description
      title: X12MasterDenialResponse
      type: object
    PolicyDocumentResult:
      description: What one payer policy document requires for one code.
      properties:
        coverage:
          anyOf:
            - $ref: '#/components/schemas/RuleAnswer'
            - type: 'null'
        document_id:
          title: Document Id
          type: string
        document_title:
          anyOf:
            - type: string
            - type: 'null'
          title: Document Title
        misc_requirements:
          anyOf:
            - $ref: '#/components/schemas/RuleAnswer'
            - type: 'null'
        notification:
          anyOf:
            - $ref: '#/components/schemas/RuleAnswer'
            - type: 'null'
        other:
          anyOf:
            - additionalProperties:
                $ref: '#/components/schemas/RuleAnswer'
              type: object
            - type: 'null'
          description: Other outcomes the document sets
          title: Other
        prior_authorization:
          anyOf:
            - $ref: '#/components/schemas/RuleAnswer'
            - type: 'null'
        site_of_service_review:
          anyOf:
            - $ref: '#/components/schemas/RuleAnswer'
            - type: 'null'
      required:
        - document_id
      title: PolicyDocumentResult
      type: object
    RuleAnswer:
      description: One outcome from a payer policy document's approved rules.
      properties:
        because:
          anyOf:
            - type: string
            - type: 'null'
          description: The source sentence
          title: Because
        near_miss:
          anyOf:
            - items:
                additionalProperties: true
                type: object
              type: array
            - type: 'null'
          description: >-
            Rules for this code that did not match, and which conditions were
            unmet
          title: Near Miss
        pages:
          anyOf:
            - items:
                type: integer
              type: array
            - type: 'null'
          title: Pages
        rule_id:
          anyOf:
            - type: string
            - type: 'null'
          description: The winning rule
          title: Rule Id
        rule_ids:
          anyOf:
            - items:
                type: string
              type: array
            - type: 'null'
          description: Conflicting rules (value = conflict)
          title: Rule Ids
        section:
          anyOf:
            - type: string
            - type: 'null'
          description: Section title the rule comes from
          title: Section
        value:
          description: e.g. required | not_required | not_listed | conflict
          title: Value
          type: string
      required:
        - value
      title: RuleAnswer
      type: object
  securitySchemes:
    APIKeyHeader:
      in: header
      name: X-API-Key
      type: apiKey

````

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