> ## 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.

# Healthcare payer types

> Medicare, Medicaid, commercial, managed care, and specialty payers explained for billing

A **payer** is the entity responsible for paying healthcare claims. Each payer type has different coverage rules, filing deadlines, and appeal processes. RCI's **L4 (Payer) knowledge layer** resolves payer-specific rules so you can bill correctly regardless of the payer.

## 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).

| Part       | Covers                                          | Billing Form    | Payment System        |
| ---------- | ----------------------------------------------- | --------------- | --------------------- |
| **Part A** | Inpatient hospital, SNF, hospice, home health   | UB-04 (837I)    | IPPS, SNF PPS, HH PPS |
| **Part B** | Physician services, outpatient, DME, labs       | CMS-1500 (837P) | MPFS, OPPS            |
| **Part C** | Medicare Advantage (private managed care plans) | Varies by plan  | Plan-specific         |
| **Part D** | Prescription drugs                              | Pharmacy claim  | Plan-specific         |

**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

| Type    | Network Requirement           | Referrals                    | Out-of-Network                   |
| ------- | ----------------------------- | ---------------------------- | -------------------------------- |
| **HMO** | Must use in-network providers | PCP referral required        | Not covered (except emergencies) |
| **PPO** | In-network preferred          | No referrals needed          | Covered at lower rate            |
| **POS** | In-network preferred          | PCP referral for specialists | Covered at lower rate            |
| **EPO** | Must use in-network providers | No referrals needed          | Not covered (except emergencies) |

**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:

```bash theme={null}
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 Part B"}'
```

The L4 response includes:

| Field                 | Example                             | Description                                      |
| --------------------- | ----------------------------------- | ------------------------------------------------ |
| `timely_filing`       | `12 months`                         | Deadline to submit the initial claim             |
| `appeal_deadline`     | `120 days`                          | Deadline to file first-level appeal              |
| `appeal_levels`       | `["Redetermination", "QIC", ...]`   | Available appeal tiers                           |
| `prior_auth_required` | `false`                             | Whether the procedure requires pre-authorization |
| `billing_form`        | `CMS-1500`                          | Required claim form                              |
| `modifier_rules`      | `["26 for professional component"]` | Payer-specific modifier guidance                 |

<Info>
  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.
</Info>