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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
US
CMS-NSA-IDR-2026-Q4-FED
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Centers for Medicare & Medicaid Services (CMS) CCIIO & EBSA Federal IDR Portal — National Docket
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National Federal Jurisdiction, US
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Filing / IDR Window: 2026-12-03
[CMS-NSA-IDR-2026-Q4-FED] Federal Blue Cross Blue Shield of Federal 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 Federal 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 Blue Cross Blue Shield of Federal & UnitedHealthcare.
Cohort MRF 75th-Pct Value
$1,250,000
Target % of Medicare
220.0% MPFS
Statutory Authority
CMS-MPFS-2026-NAT (National Conversion Factor $33.29 & 45 CFR § 149.510 IDR Precedent)
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 | Colonoscopy, Flexible; Diagnostic, Including Collection of Specimen(s) by Brushing or Washing (ASC + Pro) | CLAIM | 690 | $446.90 | $964.65 | $1,220.80 |
| CPT-45385 | Colonoscopy, Flexible; with Removal of Tumor(s), Polyp(s), or Other Lesion(s) by Snare Technique | CLAIM | 520 | $610.40 | $1,297.10 | $1,618.65 |
| CPT-43239 | Esophagogastroduodenoscopy (EGD), Flexible, Transoral; with Biopsy, Single or Multiple | CLAIM | 480 | $419.65 | $882.90 | $1,128.15 |
| CPT-45380 | Colonoscopy, Flexible; with Biopsy, Single or Multiple (Modifier 59 / XU Distinct Lesion Audit) | CLAIM | 430 | $539.55 | $1,139.05 | $1,427.90 |
2. Regional Peer Specialty Groups & EIN/NPI MRF Comparables (API #11)
USPI National Ambulatory Surgery NetworkSCA Health Multi-Specialty Surgical PartnersAMSURG National Endoscopy & Ophthalmology CentersSurgery Partners National Orthopaedic & SpineRegent Surgical Health Ambulatory Centers