> ## 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.

# Payer system integration

> Embed billing knowledge into claims adjudication, utilization review, and network management

RCI integrates with payer adjudication systems to provide coding validation, medical necessity assessment, and payment benchmarking.

## Adjudication pipeline

```
Claim received (837P / 837I)
         │
    ┌────▼──────────────────────────────────┐
    │   Your Adjudication System            │
    │                                       │
    │   ┌───────────────────────────────┐   │
    │   │   RCI Knowledge Layer         │   │
    │   │                               │   │
    │   │   Validate facility type      │   │
    │   │   Validate coding             │   │
    │   │   Check medical necessity     │   │
    │   │   Calculate expected payment  │   │
    │   └───────────────────────────────┘   │
    │                                       │
    │   Clean → Auto-adjudicate             │
    │   Flagged → Queue for review          │
    │   Invalid → Deny with reason          │
    └───────────────────────────────────────┘
```

## Use cases

### Automated coding validation

Before adjudicating, verify the submitted CPT codes are appropriate for the facility type, care setting, and documented diagnoses:

```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": "99214",
    "payer": "Medicare",
    "care_setting": "outpatient"
  }'
```

Check the L5 (Service Group) layer for documentation requirements and coding rules. Compare against what the provider submitted.

### Medical necessity review

For high-cost procedures, pre-authorization requests, or flagged claims:

```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": "Does M17.11 support medical necessity for CPT 27447?",
    "cpt_code": "27447",
    "dx_codes": ["M17.11"],
    "clinical_notes": "Severe OA, failed conservative treatment 6 months."
  }'
```

RCI evaluates against NCD/LCD criteria and returns an assessment with confidence scores. All agent decisions are audited by SENTINEL for quality and security.

### Payment benchmarking

Compare your contracted rates against MPFS-calculated expected payment:

```bash theme={null}
curl -X POST https://api-dev.rcintell.com/v1/knowledge/payment-calc \
  -H "X-API-Key: kp_test_..." \
  -H "Content-Type: application/json" \
  -d '{"ccn": "170001", "cpt": "99214"}'
```

Use the GPCI-adjusted RVU calculation as a baseline for evaluating contracted provider rates across your network.

### Network management

Use L1 (Location) data to understand geographic cost factors when building provider networks:

* **GPCI values** per area for fee schedule modeling
* **MAC jurisdiction** for claims processing routing
* **HPSA designation** for shortage area bonus calculations

## Integration methods

| Method     | Best for                               | Latency              |
| ---------- | -------------------------------------- | -------------------- |
| REST API   | Batch adjudication, backend processing | Under 100ms per call |
| Webhooks   | Async medical necessity results        | Event-driven         |
| MCP Server | AI-assisted utilization review tools   | Real-time            |

## Security and compliance

* All agent decisions include SENTINEL audit scores
* PHI exposure detection in reasoning traces
* Full audit trail exportable as JSON/CSV
* HIPAA BAA available on Enterprise plans