Clearinghouse integration

RCI plugs into your clearinghouse pipeline to validate and enrich claims before they reach payers. This reduces rejection rates, speeds up payment, and gives your customers a better experience.

Integration architecture

Provider submits claim (837P / 837I)
         │
    ┌────▼──────────────────────────────────┐
    │   Your Clearinghouse Pipeline         │
    │                                       │
    │   ┌───────────────────────────────┐   │
    │   │   RCI Knowledge Validation    │   │
    │   │                               │   │
    │   │   L2: Correct billing form?   │   │
    │   │   L3: Correct POS code?       │   │
    │   │   L4: Filing deadline ok?     │   │
    │   │   L5: Valid code + modifiers? │   │
    │   │   L6: Payment in range?       │   │
    │   └───────────────────────────────┘   │
    │                                       │
    │   Pass → Route to payer               │
    │   Fail → Return to provider           │
    └───────────────────────────────────────┘

What RCI validates

Check	Knowledge Layer	Catches
Billing form matches facility type	L2	CMS-1500 submitted for institutional facility
POS code matches care setting	L3	Wrong place of service for the facility/setting
TOB code matches facility	L2	Incorrect type of bill for facility type
Modifiers appropriate for setting	L3, L5	Missing or incorrect modifiers
Filing deadline not expired	L4	Claims submitted past timely filing limit
Prior auth indicated	L4	Services that typically require prior auth
Payment in expected range	L6	Billed amount wildly different from MPFS expected

Per-claim validation call

For each claim, resolve the knowledge and validate:

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",
    "care_setting": "outpatient"
  }'

Facility-level caching

L1-L4 data is the same for all claims from a given facility + payer. Cache at the facility level and only call L5-L6 (which require CPT) per claim line:

# Cache once per facility
curl https://api-dev.rcintell.com/v1/knowledge/layers/170001 \
  -H "X-API-Key: kp_test_..."

# Per claim line — add CPT for L5-L6
curl https://api-dev.rcintell.com/v1/knowledge/layers/170001/l6?cpt=99213 \
  -H "X-API-Key: kp_test_..."

Connecting to eligibility and claims APIs

RCI provides the knowledge — your clearinghouse provides the connectivity. Use RCI alongside your existing connections to payer eligibility (270/271) and claims (837) systems:

Before submission: RCI validates the claim against billing rules
Your pipeline: Routes the validated claim to the payer
After denial: RCI’s denial resolution agent generates appeal strategies
ERA processing: When 835 ERAs return, use RCI to interpret CARC/RARC codes

Pricing for clearinghouses

Enterprise plans include volume-based pricing optimized for high-throughput processing. Contact sales@rcintell.com for clearinghouse-specific terms.

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Platform

Clearinghouse integration

Integration architecture

What RCI validates

Per-claim validation call

Facility-level caching

Connecting to eligibility and claims APIs

Pricing for clearinghouses

​Integration architecture

​What RCI validates

​Per-claim validation call

​Facility-level caching

​Connecting to eligibility and claims APIs

​Pricing for clearinghouses

Integration architecture

What RCI validates

Per-claim validation call

Facility-level caching

Connecting to eligibility and claims APIs

Pricing for clearinghouses