> ## 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.

# Compose directory + PA + fee + policy for a claim

> Single-call claim context for Kustode / pilot integrations.

Combines Postgres payer knowledge (filing, appeals, denial patterns, PA
rules), CRD-style prior-auth determination, ClickHouse fee RVUs, and
CMS/payer policy rules for the given code.



## OpenAPI

````yaml /docs/openapi.client.json get /v1/payers/{slug}/claim-intelligence
openapi: 3.1.0
info:
  description: >-
    Client API for RCIntel. Admin ingest, catalog sync, and internal audit
    routes are omitted. 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: >-
      Geographic payer policy lookup (national NCD vs MAC LCD vs state). Query
      payer, code, state, plan_type. Each row includes geo_scope and
      document_version.
    name: policies
  - 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.
    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
  - description: Health checks, service metadata, and Prometheus metrics.
    name: system
paths:
  /v1/payers/{slug}/claim-intelligence:
    get:
      tags:
        - payers
      summary: Compose directory + PA + fee + policy for a claim
      description: |-
        Single-call claim context for Kustode / pilot integrations.

        Combines Postgres payer knowledge (filing, appeals, denial patterns, PA
        rules), CRD-style prior-auth determination, ClickHouse fee RVUs, and
        CMS/payer policy rules for the given code.
      operationId: claim_intelligence_v1_payers__slug__claim_intelligence_get
      parameters:
        - description: Normalized payer slug identifier.
          in: path
          name: slug
          required: true
          schema:
            title: Slug
            type: string
        - description: CPT/HCPCS code (e.g. 90837)
          in: query
          name: code
          required: true
          schema:
            description: CPT/HCPCS code (e.g. 90837)
            minLength: 1
            title: Code
            type: string
        - description: Modifier (e.g. HO)
          in: query
          name: modifier
          required: false
          schema:
            anyOf:
              - type: string
              - type: 'null'
            description: Modifier (e.g. HO)
            title: Modifier
        - description: Plan type for PA resolution
          in: query
          name: plan_type
          required: false
          schema:
            anyOf:
              - type: string
              - type: 'null'
            description: Plan type for PA resolution
            title: Plan Type
        - description: Service category for PA fallback
          in: query
          name: service_category
          required: false
          schema:
            anyOf:
              - type: string
              - type: 'null'
            default: mental_health
            description: Service category for PA fallback
            title: Service Category
        - description: State code
          in: query
          name: state
          required: false
          schema:
            anyOf:
              - type: string
              - type: 'null'
            description: State code
            title: State
      responses:
        '200':
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/ClaimIntelligenceResponse'
          description: Successful Response
        '422':
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/HTTPValidationError'
          description: Validation Error
      security:
        - APIKeyHeader: []
components:
  schemas:
    ClaimIntelligenceResponse:
      description: >-
        Single-call compose of directory + PA + fee + policy for a claim
        context.
      properties:
        appeal_rules:
          items:
            $ref: '#/components/schemas/AppealRuleResponse'
          title: Appeal Rules
          type: array
        code:
          title: Code
          type: string
        denial_patterns:
          items:
            $ref: '#/components/schemas/DenialPatternResponse'
          title: Denial Patterns
          type: array
        edi_payer_ids:
          additionalProperties: true
          title: Edi Payer Ids
          type: object
        fee:
          anyOf:
            - $ref: '#/components/schemas/ClaimFeeSnippet'
            - type: 'null'
        filing_rules:
          items:
            $ref: '#/components/schemas/FilingRuleResponse'
          title: Filing Rules
          type: array
        modifier:
          anyOf:
            - type: string
            - type: 'null'
          title: Modifier
        payer_name:
          title: Payer Name
          type: string
        payer_slug:
          title: Payer Slug
          type: string
        payer_type:
          title: Payer Type
          type: string
        plan_type:
          anyOf:
            - type: string
            - type: 'null'
          title: Plan Type
        policy_rules:
          items:
            $ref: '#/components/schemas/ClaimPolicyRule'
          title: Policy Rules
          type: array
        prior_auth:
          anyOf:
            - additionalProperties: true
              type: object
            - type: 'null'
          title: Prior Auth
        prior_auth_rules:
          items:
            $ref: '#/components/schemas/PriorAuthRuleResponse'
          title: Prior Auth Rules
          type: array
      required:
        - payer_slug
        - payer_name
        - payer_type
        - code
      title: ClaimIntelligenceResponse
      type: object
    HTTPValidationError:
      properties:
        detail:
          items:
            $ref: '#/components/schemas/ValidationError'
          title: Detail
          type: array
      title: HTTPValidationError
      type: object
    AppealRuleResponse:
      properties:
        appeal_level:
          title: Appeal Level
          type: integer
        deadline_days:
          title: Deadline Days
          type: integer
        external_review_deadline_days:
          anyOf:
            - type: integer
            - type: 'null'
          title: External Review Deadline Days
        level_name:
          anyOf:
            - type: string
            - type: 'null'
          title: Level Name
        peer_to_peer_available:
          default: false
          title: Peer To Peer Available
          type: boolean
        required_documents:
          items:
            type: string
          title: Required Documents
          type: array
        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'
          title: Success Rate
      required:
        - appeal_level
        - deadline_days
      title: AppealRuleResponse
      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
        success_rate:
          anyOf:
            - type: number
            - type: 'null'
          title: Success Rate
      title: DenialPatternResponse
      type: object
    ClaimFeeSnippet:
      description: Fee-schedule / RVU slice for claim intelligence.
      properties:
        code:
          title: Code
          type: string
        conversion_factor:
          anyOf:
            - type: number
            - type: 'null'
          title: Conversion Factor
        modifier:
          anyOf:
            - type: string
            - type: 'null'
          title: Modifier
        mp_rvu:
          anyOf:
            - type: number
            - type: 'null'
          title: Mp Rvu
        pe_rvu_facility:
          anyOf:
            - type: number
            - type: 'null'
          title: Pe Rvu Facility
        pe_rvu_nonfacility:
          anyOf:
            - type: number
            - type: 'null'
          title: Pe Rvu Nonfacility
        quarter:
          anyOf:
            - type: integer
            - type: 'null'
          title: Quarter
        source:
          anyOf:
            - type: string
            - type: 'null'
          title: Source
        work_rvu:
          anyOf:
            - type: number
            - type: 'null'
          title: Work Rvu
        year:
          anyOf:
            - type: integer
            - type: 'null'
          title: Year
      required:
        - code
      title: ClaimFeeSnippet
      type: object
    FilingRuleResponse:
      properties:
        claim_type:
          anyOf:
            - type: string
            - type: 'null'
          title: Claim Type
        effective_date:
          anyOf:
            - format: date-time
              type: string
            - type: 'null'
          title: Effective Date
        expiration_date:
          anyOf:
            - format: date-time
              type: string
            - type: 'null'
          title: Expiration Date
        plan_override_days:
          additionalProperties:
            type: integer
          title: Plan Override Days
          type: object
        standard_days:
          title: Standard Days
          type: integer
        state_override_days:
          additionalProperties:
            type: integer
          title: State Override Days
          type: object
      required:
        - standard_days
      title: FilingRuleResponse
      type: object
    ClaimPolicyRule:
      description: Policy rule row from CMS or payer-linked marts.
      properties:
        action:
          anyOf:
            - type: string
            - type: 'null'
          title: Action
        change_type:
          anyOf:
            - type: string
            - type: 'null'
          title: Change Type
        code:
          title: Code
          type: string
        doc_id:
          default: ''
          title: Doc Id
          type: string
        effective_from:
          anyOf:
            - type: string
            - type: 'null'
          title: Effective From
        kind:
          default: ''
          title: Kind
          type: string
        license_kind:
          anyOf:
            - type: string
            - type: 'null'
          title: License Kind
        payer_slug:
          anyOf:
            - type: string
            - type: 'null'
          title: Payer Slug
        pdf_uri:
          anyOf:
            - type: string
            - type: 'null'
          title: Pdf Uri
        rule_text:
          default: ''
          title: Rule Text
          type: string
        source_key:
          default: ''
          title: Source Key
          type: string
        trigger_condition:
          anyOf:
            - type: string
            - type: 'null'
          title: Trigger Condition
      required:
        - code
      title: ClaimPolicyRule
      type: object
    PriorAuthRuleResponse:
      properties:
        delegation_vendor:
          anyOf:
            - type: string
            - type: 'null'
          title: Delegation Vendor
        gold_card_eligible:
          default: false
          title: Gold Card Eligible
          type: boolean
        pa_required:
          default: true
          title: Pa Required
          type: boolean
        portal_url:
          anyOf:
            - type: string
            - type: 'null'
          title: Portal Url
        required_documents:
          items:
            type: string
          title: Required Documents
          type: array
        service_category:
          title: Service Category
          type: string
        turnaround_standard_days:
          anyOf:
            - type: integer
            - type: 'null'
          title: Turnaround Standard Days
        turnaround_urgent_hours:
          anyOf:
            - type: integer
            - type: 'null'
          title: Turnaround Urgent Hours
      required:
        - service_category
      title: PriorAuthRuleResponse
      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
  securitySchemes:
    APIKeyHeader:
      in: header
      name: X-API-Key
      type: apiKey

````