Government payers
Medicare
The federal health insurance program for adults 65+, people with disabilities, and ESRD patients. Administered by CMS through regional MACs (Medicare Administrative Contractors).
Key billing rules: Timely filing is 12 months from date of service. Appeals follow the 5-level Medicare process. NCCI edits and MUE limits apply to all Part B claims.
Medicaid
Joint federal-state program covering low-income individuals. Each state administers its own program with different covered services, rates, and filing rules. Key billing rules: Timely filing varies by state (90 days to 12 months). Many states use managed care organizations (MCOs) for claims processing. Prior authorization requirements are state-specific.TRICARE
Health coverage for active-duty military, retirees, and dependents. Administered by Defense Health Agency. Key billing rules: Follows Medicare payment rates for most services. Timely filing is 1 year from date of service. Uses its own regional contractors.Commercial payers
Traditional indemnity
Fee-for-service plans where the insurer pays a percentage of allowed charges. Increasingly rare, but still used in some employer plans.Managed care organizations
Key billing rules: Each plan has its own fee schedule, prior auth requirements, and timely filing limits (typically 90-180 days). Always verify eligibility before rendering services.
Specialty payers
Workers’ compensation
Covers work-related injuries and illnesses. State-regulated with mandatory employer coverage in most states. Key billing rules: First report of injury required. State-specific fee schedules (not Medicare rates). No patient cost-sharing. Timely filing varies by state.Auto insurance (PIP/MedPay)
Personal Injury Protection or Medical Payments coverage for motor vehicle accidents. Key billing rules: State-specific no-fault laws determine coverage. Separate claim filing process from health insurance. May require coordination of benefits with health plan.VA (Veterans Affairs)
Federal healthcare system for eligible veterans. Services provided at VA facilities or through the Community Care program.How RCI handles payers in L4
When you resolve knowledge with a payer name, RCI’s L4 layer returns payer-specific rules:When you submit agent jobs with a
ccn, the agent automatically receives L4 payer context — including filing deadlines and appeal rules — so its recommendations account for payer-specific requirements.