> ## 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.

# RCI for Providers & Clinical Staff

> Medical necessity, prior auth, expected reimbursement, and coding context at the point of care

17% of insured Americans had coverage denied for care their doctor recommended. Nearly 6 in 10 said their care was delayed. More than half never challenged the denial — most didn't even know they could. You're making clinical decisions. RCI makes sure those decisions don't hit a billing wall — before the patient leaves.

## What RCI does for you

### At the point of care

| Situation                         | How RCI helps                                                                         |
| --------------------------------- | ------------------------------------------------------------------------------------- |
| **Ordering a procedure**          | Check if the payer requires prior authorization before you order                      |
| **Documenting the visit**         | Know the documentation requirements for the E/M level you're billing                  |
| **Explaining costs to a patient** | Show expected reimbursement so the patient understands their financial responsibility |
| **Checking medical necessity**    | Validate that the diagnosis supports the procedure before it's performed              |

### After the visit

| Situation                              | How RCI helps                                                                                              |
| -------------------------------------- | ---------------------------------------------------------------------------------------------------------- |
| **Claim denied for medical necessity** | AI agent validates your clinical reasoning against NCD/LCD criteria and generates supporting documentation |
| **Prior auth denial**                  | Get the payer's appeal process and deadlines, plus a recommended strategy                                  |
| **Coding questions**                   | Your coders can use the code research agent to verify the CPT matches what was performed                   |

## Example: Pre-procedure check

A patient needs a total knee arthroplasty (CPT 27447) for severe osteoarthritis. Before scheduling:

### Check medical necessity

```bash theme={null}
curl -X POST https://api-dev.rcintell.com/v1/agents/medical-necessity \
  -H "X-API-Key: kp_test_..." \
  -H "Content-Type: application/json" \
  -d '{
    "query": "Is total knee arthroplasty medically necessary?",
    "cpt_code": "27447",
    "dx_codes": ["M17.11"],
    "clinical_notes": "Severe OA right knee. Failed 6 months PT, NSAIDs, 2 corticosteroid injections. Significant functional limitation.",
    "ccn": "170001"
  }'
```

RCI tells you:

* **Assessment**: Medically necessary
* **Supporting LCD**: L33728 — Total Knee Arthroplasty
* **Criteria met**: Failed conservative treatment ≥3 months, radiographic evidence
* **Documentation checklist**: What you need in the chart for the claim to be clean

### Check prior auth and expected payment

```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": "27447",
    "payer": "Cigna",
    "care_setting": "inpatient"
  }'
```

RCI tells you:

* **Prior auth**: Required for most commercial payers — check specific plan
* **Expected payment**: RVU-based estimate for this facility's geography
* **Filing deadline**: 90-365 days (varies by contract)
* **Appeal levels**: Internal appeal → External review

## What providers care about in each layer

| Layer                | Why it matters to you                                                                                                                                       |
| -------------------- | ----------------------------------------------------------------------------------------------------------------------------------------------------------- |
| **L1 Location**      | Your facility's GPCI affects how much the payer reimburses — this is why the same procedure pays differently in Manhattan vs rural Kansas                   |
| **L3 Setting**       | Inpatient vs outpatient vs office changes the rate type and modifier requirements                                                                           |
| **L4 Payer**         | Prior auth rules vary dramatically by payer — Medicare rarely requires it, commercial payers almost always do for surgical procedures                       |
| **L5 Service Group** | Documentation requirements differ by procedure category — E/M visits need medical decision-making documentation, surgical procedures need operative reports |
| **L6 Service**       | The actual expected payment, so you can have honest financial conversations with patients                                                                   |

## Integrating with your workflow

RCI fits into your EHR workflow at key decision points:

```
Patient arrives → Check payer rules (L4: prior auth needed?)
    │
Provider orders procedure → Check medical necessity (agent)
    │
Procedure performed → Coding guidance (agent: correct CPT?)
    │
Claim submitted → Payment expectation (L6: expected $)
    │
If denied → Denial resolution (agent: appeal strategy)
```

Your EHR vendor can embed these calls directly. See the [platform integration guide](/docs/for-platforms/overview).

## Related APIs

| Need                        | Guide                                   |
| --------------------------- | --------------------------------------- |
| Cited coverage policy       | [Payer policies](/docs/policies)        |
| 340B access                 | [340B](/docs/policy-340b)               |
| Prior auth before the order | [Prior authorization](/docs/prior-auth) |
| Expected payment            | [Fee schedules](/docs/fee-schedules)    |