Knowledge layers overview

The RCI knowledge layer resolves healthcare billing context through six hierarchical layers. Each layer builds on the previous, creating a complete billing picture from a single CCN (Medicare Provider Number).

The six layers

Layer	Name	Input	Resolves
L1	Physical Location	CCN → state	GPCI values, MAC jurisdiction, Medicaid program, HPSA designation, timely filing
L2	Facility Type	CCN → type range	Payment system (OPPS/MPFS/IPPS), billing form (CMS-1500/UB-04), TOB codes
L3	Care Setting	L2 output	Place of Service codes, modifier requirements, site-of-service differentials
L4	Payer	Payer name	Payer-specific rules, timely filing limits, appeal deadlines, prior authorization
L5	Service Group	CPT prefix	E/M, surgical, radiology group rules, documentation requirements
L6	Service	CPT + L1 GPCI	Specific RVUs, GPCI-adjusted payment calculation, conversion factor

How resolution works

When you submit a knowledge resolution request, the resolver chains all six layers in sequence. Each layer receives the output of prior layers so it can use accumulated context.

CCN "170001" → parse_ccn() → state="Kansas", type="Short-term Hospital"
  │
  ├─ L1: Kansas → GPCI(1.000, 0.891, 0.407), MAC="Jurisdiction 5"
  │       Medicaid="KanCare", timely filing, balance billing rules
  │
  ├─ L2: Short-term Hospital (CCN 0000-0879)
  │       Payment: OPPS (outpatient), IPPS (inpatient)
  │       Billing form: CMS-1500 / 837P
  │       TOB codes: 131 (outpatient), 111 (inpatient)
  │
  ├─ L3: Outpatient → POS=22, modifier requirements
  │       Site-of-service differential applied
  │
  ├─ L4: Medicare → 12-month filing limit, 120-day appeal deadline
  │       5 appeal levels, MSP rules, ABN requirements
  │
  ├─ L5: CPT 99213 → E/M Office Visit (established patient)
  │       Documentation: medical decision-making or time-based
  │
  └─ L6: 99213 → Work RVU=1.30, PE RVU=0.99, MP RVU=0.10
              → GPCI-adjusted: (1.30×1.000 + 0.99×0.891 + 0.10×0.407)
              → Payment = $80.78 (at CF $32.35)

Partial resolution

Not all layers require all inputs:

L1-L2 require only the CCN
L3 benefits from a care_setting parameter but has sensible defaults
L4 requires a payer parameter (defaults to Medicare)
L5-L6 require a cpt code — they are skipped if not provided

This means you can call /v1/knowledge/resolve with just a CCN and get L1-L4, then add CPT later for the full stack.

Data sources

Layer	Primary Source
L1	CMS GPCI tables, MAC jurisdiction assignments
L2	CMS provider classification, facility type ranges
L3	CMS Place of Service codes, modifier guidelines
L4	Payer documentation, CMS Medicare rules, state Medicaid programs
L5	AMA CPT guidelines, CMS NCCI edits
L6	CMS MPFS Relative Value Files, annual conversion factor

API endpoints

Endpoint	Description
`POST /v1/knowledge/resolve`	Full L1-L6 resolution
`GET /v1/knowledge/layers/{ccn}`	All layers for a CCN
`GET /v1/knowledge/layers/{ccn}/{layer}`	Single layer
`POST /v1/knowledge/billing-guide`	Billing guidelines
`POST /v1/knowledge/payment-calc`	Payment calculation

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Knowledge layers overview

The six layers

How resolution works

Partial resolution

Data sources

API endpoints

​The six layers

​How resolution works

​Partial resolution

​Data sources

​API endpoints

The six layers

How resolution works

Partial resolution

Data sources

API endpoints