Payer Clinical Policy Bulletin (CPB), LCD/NCD & Prior-Auth Shredder

Shreds commercial payer Clinical Policy Bulletins (UHC, Anthem, Aetna, Cigna, BCBS), CMS LCD/NCD coverage policies, step-therapy gates, and timely-filing deadlines into structured prior-authorization and appeal checklists.

{
  "project_id": "TXDOI-MRF-CPT-29881-DFW",
  "specification_text": "Commercial Payer Clinical Policy Bulletin CPB-0592: CPT 29881 Knee Arthroscopy & CPT 27447 Total Knee Arthroplasty require 6 weeks documented conservative physical therapy, Kellgren-Lawrence Grade >= 3 imaging, and prior authorization. Timely filing: 90 days.",
  "state_dot": "TX"
}

{
  "status": "success",
  "project_id": "TXDOI-MRF-CPT-29881-DFW",
  "divisions_detected": [
    "CPB-0592 Surgical Coverage Criteria",
    "CMS LCD L35094 Orthopedic Criteria",
    "ERISA 29 CFR 2560.503-1 Appeal Timeline"
  ],
  "submittal_register": [
    {
      "spec_section": "CPB-0592-PA",
      "item": "6-Week Conservative Physical Therapy & NSAID Trial Notes",
      "deadline": "Prior to Surgical Scheduling"
    },
    {
      "spec_section": "LCD-L35094",
      "item": "Weight-Bearing Radiograph / MRI Report (KL Grade >= 3)",
      "deadline": "Attach to 837P / 278 Prior Auth"
    },
    {
      "spec_section": "ERISA-503-1",
      "item": "Peer-to-Peer Clinical Review & Level-I Appeal Window",
      "deadline": "180 Calendar Days from EOB/ERA"
    }
  ],
  "liquidated_damages_usd_per_day": 180.0,
  "retainage_pct": 14.5
}

Commercial Payer TiC MRF Allowed-Amount & QPA Benchmark Modeler

Benchmarks CPT, HCPCS, APC, and MS-DRG codes against CMS Transparency in Coverage (45 CFR 147.212) commercial payer Machine-Readable Files (MRFs) to compute 25th, 50th (Median QPA), and 75th percentile negotiated rates.

{
  "state_dot": "TX",
  "district": "Dallas-Fort Worth MSA (Locality 04412-11)",
  "pay_items": [
    {
      "item_code": "CPT-29881",
      "description": "Knee Arthroscopy, Surgical, with Meniscectomy (ASC + Pro)",
      "unit": "CLAIM",
      "quantity": 420
    },
    {
      "item_code": "CPT-27447",
      "description": "Total Knee Arthroplasty (Condyle and Plateau; Medial & Lateral)",
      "unit": "CLAIM",
      "quantity": 115
    }
  ]
}

{
  "status": "success",
  "state_dot": "TX",
  "historical_lettings_sampled": 384,
  "unit_price_benchmarks": [
    {
      "item_code": "CPT-29881",
      "unit": "CLAIM",
      "low_25th_usd": 640.0,
      "median_50th_usd": 1485.0,
      "recommended_unit_usd": 1890.0,
      "extended_total_usd": 793800.0
    },
    {
      "item_code": "CPT-27447",
      "unit": "CLAIM",
      "low_25th_usd": 4850.0,
      "median_50th_usd": 9420.0,
      "recommended_unit_usd": 11850.0,
      "extended_total_usd": 1362750.0
    }
  ],
  "estimated_total_bid_usd": 2156550.0
}

CMS Medicare MPFS RVU, Geographic GPCI & ASC Facility Calculator

Computes exact CMS Medicare Physician Fee Schedule (MPFS) and Ambulatory Surgical Center (ASC) baselines using Work/PE/MP RVUs, county Geographic Practice Cost Indices (GPCI), and commercial percentage-of-Medicare multiples.

{
  "state": "TX",
  "county": "Dallas County",
  "construction_type": "Outpatient_ASC_and_Physician",
  "crew_classifications": [
    {
      "craft": "CPT 29881 \u2014 Facility ASC Payment Rate (Wage-Adjusted)",
      "weekly_hours": 40
    },
    {
      "craft": "CPT 29881 \u2014 Physician Professional Fee (215% Medicare Target)",
      "weekly_hours": 40
    }
  ]
}

{
  "status": "success",
  "wage_decision_id": "CMS-MPFS-2026B-TX-04412",
  "county": "Dallas County, TX",
  "wh347_certified_payroll_ready": true,
  "craft_rates": [
    {
      "craft": "CPT 29881 \u2014 Facility ASC Payment Rate (Wage-Adjusted)",
      "base_hourly_usd": 1124.5,
      "fringe_hourly_usd": 360.5,
      "loaded_hourly_usd": 1485.0
    },
    {
      "craft": "CPT 29881 \u2014 Physician Professional Fee (215% Medicare Target)",
      "base_hourly_usd": 582.4,
      "fringe_hourly_usd": 670.1,
      "loaded_hourly_usd": 1252.5
    }
  ]
}

52-Portal Commercial Payer MRF, ERISA & NSA IDR Dispute Feed

Streams normalized commercial payer TiC MRF rate-disparity cohorts, CMS Federal NSA IDR arbitration benchmarks, and State DOI/APCD fee schedule updates across all 50 U.S. States.

{
  "state": "ALL_50_STATES",
  "portal_count": 52,
  "naics_filter": [
    "621111",
    "621493",
    "622110"
  ],
  "limit": 25
}

{
  "status": "success",
  "portals_monitored": 52,
  "states_covered": 50,
  "active_lettings_count": 12,
  "sample_letting": {
    "project_id": "TXDOI-MRF-CPT-29881-DFW",
    "agency": "Texas Department of Insurance (TDI) & CMS Novitas JH Payer MRF Index",
    "title": "UHC & BCBS-TX Commercial MRF Rate Disparity & NSA IDR Benchmark (CPT 29881 / 27447)",
    "engineers_estimate_usd": 1845000.0,
    "dbe_goal_pct": 14.5
  }
}

CMS NCCI PTP Edits, MUE Limits & Modifier 25/59/XU Bundling Auditor

Audits surgical and outpatient claim lines against CMS National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) bundling edits, Medically Unlikely Edits (MUE), and Modifier 25/59/XE/XS/XP/XU unbundling rules.

{
  "project_id": "TXDOI-MRF-CPT-29881-DFW",
  "funding_agency": "Commercial_ERISA_and_CMS_NCCI",
  "bill_of_materials": [
    {
      "material": "CPT 29881 + CPT 29877 (Ipsilateral Knee Chondroplasty NCCI Column 2)",
      "category": "ncci_ptp_pair",
      "origin_country": "US",
      "cost_usd": 189000
    },
    {
      "material": "CPT 99214-25 + CPT 20610 (E/M with Major Joint Injection Mod 25)",
      "category": "modifier_25_override",
      "origin_country": "US",
      "cost_usd": 142000
    }
  ]
}

{
  "status": "success",
  "baba_compliant": true,
  "iron_steel_100pct_us_melted": true,
  "manufactured_products_domestic_pct": 98.4,
  "de_minimis_waiver_eligible": true,
  "required_certifications": [
    "Operative Note Documenting Separate Compartment / Distinct Procedural Service (Modifier 59 / XS)",
    "Separately Identifiable E/M HPI & MDM Documentation Supporting Modifier 25 Override"
  ]
}

ERISA 29 CFR 2560.503-1 Medical Necessity & Level-II Appeal Generator

Generates statutory ERISA 29 CFR 2560.503-1 Medical Necessity appeals, external IRO review demands, and peer-reviewed clinical evidence matrices to overturn CO-50, CO-96, and CO-197 prior-authorization denials.

{
  "state_dot": "TX",
  "contract_total_usd": 1845000.0,
  "dbe_goal_pct": 14.5,
  "subcontractor_quotes": [
    {
      "firm": "ERISA 29 CFR 2560.503-1 Full & Fair Review Clinical Dossier",
      "naics": "621111",
      "role": "subcontractor",
      "quote_usd": 1240000.0
    },
    {
      "firm": "AAOS / NASS Peer-Reviewed Clinical Guidelines & CPB Evidentiary Matrix",
      "naics": "621493",
      "role": "regular_dealer_supply",
      "quote_usd": 820000.0
    }
  ]
}

{
  "status": "success",
  "dbe_goal_pct": 14.5,
  "achieved_dbe_pct": 15.82,
  "goal_met": true,
  "regular_dealer_60pct_adjustment_applied": true,
  "good_faith_effort_status": "VERIFIED \u2014 ERISA 29 CFR 2560.503-1 Statutory Appeal & IRO Demand Ready"
}

HIPAA 835 ERA Remittance, CARC/RARC Denial & Underpayment Modeler

Parses HIPAA X12 835 Electronic Remittance Advice (ERA) files, CARC/RARC adjustment codes (CO-45, CO-50, CO-97, OA-23), and payer fee-schedule variances into a line-item underpayment recovery ledger.

{
  "contract_sum_usd": 1845000.0,
  "retainage_pct": 14.5,
  "line_items": [
    {
      "line_no": "CPT-29881",
      "description": "Knee Arthroscopy Meniscectomy (CARC CO-45 Underpayment Recovery)",
      "scheduled_value_usd": 793800.0,
      "completed_pct": 100.0
    },
    {
      "line_no": "CPT-27447",
      "description": "Total Knee Arthroplasty (CARC CO-50 Medical Necessity Appeal)",
      "scheduled_value_usd": 1051200.0,
      "completed_pct": 85.0
    }
  ]
}

{
  "status": "success",
  "form": "HIPAA X12 835 ERA Underpayment & CARC/RARC Recovery Ledger",
  "mobilization_cap_compliant": true,
  "front_loading_risk": "LOW",
  "net_current_payment_due_usd": 1434495.0
}

Federal No Surprises Act (NSA 45 CFR 149.510) IDR Brief & QPA Auditor

Audits payer Qualifying Payment Amount (QPA) disclosures under 45 CFR 149.140, models baseball-style Final Offer arbitration positioning, and drafts Federal Independent Dispute Resolution (IDR) position briefs.

{
  "jurisdiction": "Federal_CMS_NSA_IDR_45CFR149",
  "contract_amount_usd": 1845000.0,
  "contractor_single_limit_usd": 15000000.0,
  "contractor_aggregate_wip_usd": 42000000.0
}

{
  "status": "success",
  "statute": "Federal No Surprises Act (42 U.S.C. 300gg-111 / 45 CFR 149.510)",
  "performance_bond_pct": 100,
  "payment_bond_pct": 100,
  "estimated_bond_premium_usd": 12450.0,
  "capacity_verdict": "PASS \u2014 75th-Percentile TiC MRF Offer Supported by Acuity & Case-Mix Evidence"
}

Payer Post-Payment Recoupment, RAC/ZPIC Audit & Prompt-Pay Demand Drafter

Drafts statutory defenses against commercial payer post-payment clawbacks, SIU/RAC extrapolation audits, and State Prompt-Pay Act statutory interest demands (12%–18% APR).

{
  "project_id": "TXDOI-MRF-CPT-29881-DFW",
  "clause_type": "State_Prompt_Pay_and_ERISA_Anti_Clawback",
  "field_condition": "Payer withheld clean claims > 45 days and issued retroactive DRG/CPT downcode recoupment notice without peer-to-peer review.",
  "direct_cost_impact_usd": 148500.0,
  "schedule_delay_days": 62
}

{
  "status": "success",
  "entitlement_basis": "TX Ins. Code \u00a7 1301.103 (18% APR Penalty) & ERISA 29 CFR 2560.503-1 Adverse Benefit Protections",
  "recommended_claim_amount_usd": 173745.0,
  "critical_path_extension_days": 62
}

CAQH / PECOS Provider Roster, NPPES NPI & Payer Network Adequacy Auditor

Audits medical group NPPES Type 1/Type 2 NPIs, CMS PECOS enrollment, CAQH ProView attestation currency, and CMS 42 CFR 422.116 time-and-distance specialty network adequacy.

{
  "contractor_emr": 0.98,
  "trir": 1.1,
  "scopes": [
    "Orthopedic_Surgery_ASC",
    "Interventional_Pain_Management",
    "Diagnostic_Imaging_MRI"
  ]
}

{
  "status": "success",
  "emr_qualified": true,
  "max_emr_threshold": 1.0,
  "required_aha_modules": [
    "NPPES Type 1 & Type 2 NPI Taxonomy 207X00000X Crosswalk Verified",
    "CMS PECOS & CAQH ProView 120-Day Re-Attestation Active",
    "CMS 42 CFR 422.116 Specialty Network Adequacy Leverage Confirmed"
  ]
}

Regional Specialty Group EIN/NPI Payer MRF Contract Spread Predictor

Analyzes competing regional health systems, ASCs, and specialty medical groups by EIN/NPI inside commercial payer TiC MRF files to quantify your exact contracted rate gap (Money-Left-On-Table %).

{
  "state_dot": "TX",
  "engineers_estimate_usd": 1845000.0,
  "planholders": [
    "Texas Orthopedic Specialists PA",
    "Baylor Scott & White Surgicare",
    "Lonestar ASC LLC"
  ]
}

{
  "status": "success",
  "expected_bidder_count": 3,
  "predicted_winning_discount_vs_estimate_pct": -4.2,
  "recommended_optimal_bid_usd": 1767510.0,
  "expected_money_left_on_table_pct": 1.8
}

Value-Based Care, ASC Carve-Out & Commercial Payer Rate Term-Sheet Generator

Generates commercial payer contract renegotiation term sheets, ASC implant carve-out schedules, and anti-downcoding contract riders anchored to 75th-percentile TiC MRF benchmarks.

{
  "project_title": "DFW Multi-Specialty ASC Commercial Payer Rate Renegotiation",
  "state": "TX",
  "trades_needed": [
    "Orthopedic_Implant_Carve_Out",
    "ASC_Facility_Grouper_Floor",
    "Anti_Retaliatory_Downcoding_Rider"
  ]
}

{
  "status": "success",
  "itb_packages_generated": 3,
  "flow_down_audit": "PASS \u2014 215% Medicare MPFS Floor, Cost+15% Implant Carve-Out & 30-Day Prompt-Pay Rider Verified"
}