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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
AR
ARDOI-MRF-CPT-45378-332
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Arkansas Insurance Department (AID) & CMS TiC Payer MRF Index
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Pulaski County, AR
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Filing / IDR Window: 2026-11-20
[ARDOI-MRF-CPT-45378-332] Ar Arkansas Blue Cross and Blue Shield MRF Rate Disparity: Gastroenterology & Ambulatory Endoscopy Center (CPT 45378)
Commercial payer TiC MRF facility vs. professional rate spread audit and NCCI PTP Modifier 59/PT unbundling defense for Ar Gastroenterology Endoscopy centers (CPT 45378 Diagnostic Colonoscopy, CPT 45385 Colonoscopy with Snare Polypectomy, CPT 43239 Upper GI Endoscopy EGD with Biopsy, and CPT 00812 Screening Anesthesia) across Arkansas Blue Cross and Blue Shield & QualChoice.
Cohort MRF 75th-Pct Value
$1,640,000
Target % of Medicare
227.5% MPFS
Statutory Authority
AR-GPCI-2026 (Ark. Code Ann. § 23-79-112 (12% Prompt-Pay))
ERISA / Timely-Filing Window
120 Days
1. Commercial Payer TiC MRF Allowed-Amount Benchmarks (API #02)
| CPT / DRG Code | Clinical Procedure Description | Unit | Cohort Claims | MRF 25th Pct | MRF Median (QPA) | MRF 75th Pct |
|---|---|---|---|---|---|---|
| CPT-45378 | Diagnostic Colonoscopy with Biopsy (ASC Facility + Pro) | CLAIM | 540 | $385.40 | $907.10 | $1,142.10 |
| CPT-43239 | Upper GI Endoscopy (EGD) with Biopsy | CLAIM | 190 | $558.83 | $1,315.30 | $1,656.04 |
| CPT-99214-25 | Level 4 Established Patient Outpatient E/M with Separately Identifiable Modifier 25 | CLAIM | 1,200 | $115.00 | $172.00 | $204.00 |
2. Regional Peer Specialty Groups & EIN/NPI MRF Comparables (API #11)
OrthoArkansas Outpatient Surgery Center Little RockMartin Luther King Jr. Drive Endoscopy & SurgeryUAMS Health Orthopaedic & Spine Hospital