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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
AZ
AZDOI-MRF-CPT-29881-315
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Arizona Department of Insurance and Financial Institutions (DIFI) & CMS TiC Payer MRF Index
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Maricopa County, AZ
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Filing / IDR Window: 2026-11-23
[AZDOI-MRF-CPT-29881-315] Az Blue Cross Blue Shield of Arizona MRF Rate Disparity: Spine & Neurosurgery Outpatient Decompression/Fusion (CPT 63030)
Commercial payer TiC MRF negotiated rate percentile audit and ERISA 29 CFR 2560.503-1 clinical medical-necessity appeal cohort for Az Spine & Neurosurgery procedures (CPT 63030 Lumbar Laminotomy/Discectomy, CPT 22551 Anterior Cervical Discectomy & Fusion ACDF, CPT 63047 Lumbar Laminectomy, and CPT 64483 Transforaminal Epidural Injection) across Blue Cross Blue Shield of Arizona & UnitedHealthcare AZ.
Cohort MRF 75th-Pct Value
$2,440,000
Target % of Medicare
251.5% MPFS
Statutory Authority
AZ-GPCI-2026 (A.R.S. § 20-3102 Prompt-Pay)
ERISA / Timely-Filing Window
180 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-29881 | Knee Arthroscopy, Surgical, with Meniscectomy (ASC + Pro) | CLAIM | 580 | $678.40 | $1,579.40 | $1,992.80 |
| CPT-27447 | Total Knee Arthroplasty (Condyle and Plateau) | CLAIM | 140 | $983.68 | $2,290.13 | $2,889.56 |
| 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)
The CORE Institute Specialty Hospital PhoenixBanner University Medicine Surgery CenterHonorHealth Piper Surgery Center ScottsdaleRadiology Ltd. TucsonSimonMed Imaging