> ## 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 — The Healthcare Knowledge Layer
> The billing knowledge that prevents denials, accelerates payment, and eliminates guesswork across the revenue cycle
## The problem
Healthcare billing is broken — and the root cause isn't technology. It's knowledge.
* **15-20% of claims are denied on first submission.** Some providers see rates as high as 40%. The top reasons: coding errors, incomplete information, wrong billing form, missed filing deadlines. ([MGMA, 2024](https://www.codeemr.com/top-10-medical-billing-challenges-2025/))
* **17% of insured Americans had coverage denied** for care recommended by their doctor. Nearly 6 in 10 said their care was delayed as a result. More than half didn't challenge the denial — most didn't know they could. ([Commonwealth Fund, 2024](https://www.commonwealthfund.org/publications/issue-briefs/2024/aug/unforeseen-health-care-bills-coverage-denials-by-insurers))
* **35% of providers report staffing as their top RCM issue.** Experienced billers and coders are retiring faster than they're replaced. The knowledge walks out the door with them. ([AAPC, 2025](https://www.codeemr.com/top-10-medical-billing-challenges-2025/))
* **32-day average payment turnaround.** Delayed reimbursements disrupt cash flow and strain provider-payer relationships. ([Becker's Healthcare, 2025](https://www.codeemr.com/top-10-medical-billing-challenges-2025/))
Every one of these problems traces back to the same gap: **someone didn't know the right code, the right form, the right deadline, the right rule, or the right appeal process at the right time.**
## What RCI does
RCI is the knowledge layer for healthcare billing. It gives everyone in the revenue cycle — billers, providers, payers, clearinghouses, and the platforms that serve them — instant access to the billing rules, payment intelligence, and coding guidance they need to get claims right the first time.
Right code, right form, right deadline, right appeal. Before you submit and after you're denied.
Medical necessity, prior auth, expected reimbursement — at the point of care, not after the denial.
Validate coding, check necessity, benchmark payment — automate what your reviewers do manually.
Catch the errors that cause denials before the claim reaches the payer. Reduce rejections, not just route transactions.
Embed billing knowledge into your product. Replace internal rule engines with a single API.
Client lookups for policy, 340B, prior auth, payment, and agents.
## How RCI maps to the top billing challenges
| Industry challenge | Denial rate impact | How RCI solves it |
| ------------------------------------------------------------------------------------- | -------------------------------- | ------------------------------------------------------------------------------------ |
| **Coding errors** — wrong CPT, missing modifiers, incorrect code for setting | 30-40% of denials | AI code research agent + L5 service group rules + L3 modifier requirements |
| **Wrong billing form** — CMS-1500 submitted for institutional facility, or vice versa | Immediate rejection | L2 facility type → determines CMS-1500 vs UB-04 automatically |
| **Missed filing deadlines** — claim submitted past payer's timely filing limit | Unrecoverable denial | L4 payer rules → filing deadline per payer (Medicare: 12 months, commercial: varies) |
| **Missing prior authorization** — procedure performed without required pre-auth | CARC 197 denial | L4 payer rules → prior auth requirements flagged before the service is performed |
| **Medical necessity denials** — payer says procedure wasn't justified | \~10% of denials | Medical necessity agent → validates against NCD/LCD criteria with clinical context |
| **Incorrect place of service** — POS code doesn't match facility/setting | CARC 182 denial | L3 care setting → resolves POS code from facility type + care setting |
| **Appeal knowledge gaps** — provider doesn't know deadline, level, or strategy | Denial becomes write-off | L4 payer rules → appeal levels + deadlines; denial resolution agent → strategy |
| **Payment estimation gaps** — no visibility into expected reimbursement | Under-billing, surprise balances | L6 service → RVU × GPCI × conversion factor = expected Medicare payment |
| **Staff knowledge loss** — experienced billers retire, rules aren't documented | Systemic error increase | The entire L1-L6 knowledge graph captures institutional billing knowledge as API |
## The knowledge graph
RCI resolves billing context through six layers. Each builds on the previous — from geography to the specific dollar amount.
```
CCN "170001"
│
├─ L1 Location Kansas → GPCI values, MAC, Medicaid program
├─ L2 Facility Short-term Hospital → payment system, billing form, TOB
├─ L3 Setting Outpatient → place of service, modifiers, rate type
├─ L4 Payer Medicare → 12-month filing, 5 appeal levels, prior auth
├─ L5 Service Group CPT 99213 → E/M rules, documentation requirements
└─ L6 Service 99213 → RVU=2.22, GPCI-adjusted → Payment = $71.91
```
One API call. Six layers. The complete billing context.
```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",
"care_setting": "outpatient"
}'
```
## Free tools — no account required
Like Stedi built public EDI tools, RCI builds public billing knowledge tools. Browse, search, and use — free.
Searchable directory of payer rules, filing deadlines, appeal processes, and GPCI values.
Enter a CCN + CPT → see the full RVU/GPCI breakdown and expected Medicare payment.
Paste CARC/RARC codes → get plain-English explanation and appeal strategy.
Open catalog of TOB codes, POS codes, modifiers, NCCI edits, and revenue codes.
Paste any CCN → see the complete L1-L6 billing context for that facility.
Track payer rule changes, CMS updates, coding changes, and NCCI edits in real time.
## Three ways to integrate
JSON API with full OpenAPI spec. Works with any language.
Connect AI agents (Claude, Cursor, custom) directly to the knowledge layer.
Get notified when agent jobs complete, rules change, or audit alerts fire.
## What RCI is not
RCI is the **knowledge layer**, not the transaction layer. It doesn't submit claims, check patient eligibility, or connect to payers. It tells you what to bill, how to bill it, and what to expect back. Use it alongside your clearinghouse, EHR, and payer connections.
| RCI does | RCI does not |
| ------------------------------------------- | ---------------------------------------------- |
| Determine the correct billing form | Submit claims to payers |
| Calculate expected Medicare payment | Process real-time eligibility checks |
| Resolve denial codes with appeal strategies | Transmit X12 EDI transactions |
| Validate medical necessity against NCD/LCD | Store patient health records |
| Provide coding guidance with AI agents | Replace your EHR or practice management system |