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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
HI
HIDOI-MRF-CPT-45378-337
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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
[HIDOI-MRF-CPT-45378-337] Hi Hawaii Medical Service Association (HMSA) MRF Rate Disparity: Interventional Pain Management & Neuromodulation ASC (CPT 63650)
Commercial payer TiC MRF implant device pass-through audit and ERISA 29 CFR 2560.503-1 prior-authorization denial appeal cohort for Hi Interventional Pain Management & Neuromodulation centers (CPT 63650 Percutaneous Spinal Cord Stimulator Lead Implantation, CPT 64635 Lumbar Medial Branch Radiofrequency Ablation, CPT 64493 Lumbar Facet Joint Injection, and CPT 62323 Lumbar Interlaminar Epidural) across Hawaii Medical Service Association (HMSA) & Kaiser HI.
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)
Bone and Joint Clinic of Hawaii Honolulu ASCQueen's Medical Center POB Outpatient SurgeryStraub Benioff Medical Center Endoscopy & ASCOrthopedic Associates of Hawaii