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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
HI
HIDOI-MRF-CPT-29881
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Hawaii Insurance Division (DCCA) & CMS TiC Payer MRF Index
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Honolulu County, HI
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Filing / IDR Window: 2026-11-25
HI Commercial Payer TiC MRF & NSA IDR Cohort — CPT 29881 / 27447 Orthopedic & ASC
Commercial payer TiC MRF negotiated rate audit, CMS Medicare MPFS RVU/GPCI locality repricing, and ERISA 29 CFR § 2560.503-1 / Federal No Surprises Act (45 CFR § 149.510) IDR arbitration package for Orthopedic & ASC Surgery in HI (CPT 29881 Knee Arthroscopy & CPT 27447 Total Knee Arthroplasty).
Cohort MRF 75th-Pct Value
$1,785,000
Target % of Medicare
244.0% MPFS
Statutory Authority
HI-GPCI-2026 (HRS § 431:13-108 (15% Prompt-Pay))
ERISA / Timely-Filing Window
90 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 | 500 | $446.90 | $1,051.85 | $1,324.35 |
| CPT-43239 | Upper GI Endoscopy (EGD) with Biopsy | CLAIM | 190 | $648.00 | $1,525.18 | $1,920.31 |
| 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)
Orthopedic Associates of HawaiiHI Regional Orthopedic Associates PAHI Ambulatory Orthopedic Center LLC