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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
IL
ILDOI-MRF-CPT-29881
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Illinois Department of Insurance (IDOI) & NGS J6 MRF Index — Chicago Metro MSA
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Cook County, IL
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Filing / IDR Window: 2026-11-28
IL 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 IL (CPT 29881 Knee Arthroscopy & CPT 27447 Total Knee Arthroplasty).
Cohort MRF 75th-Pct Value
$1,645,000
Target % of Medicare
238.5% MPFS
Statutory Authority
IL-GPCI-2026-CHI (Medicare Locality 06102-16 & 215 ILCS 5/368a 9% 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-29881 | Orthopedic & ASC: Arthroscopy, Knee, Surgical; with Meniscectomy (Medial/Lateral) & CPT 27447 Total Knee | CLAIM | 420 | $640.00 | $1,185.00 | $1,495.00 |
| CPT-31255 | Nasal/Sinus Endoscopy, Surgical, with Ethmoidectomy; Total (Anterior and Posterior) | CLAIM | 245 | $1,225.70 | $2,667.70 | $3,337.20 |
| CPT-31295 | Nasal/Sinus Endoscopy, Surgical, with Dilation (Balloon) of Maxillary Sinus Ostium, Transnasal | CLAIM | 195 | $1,493.50 | $3,275.40 | $4,099.40 |
| CPT-30520 | Septoplasty or Submucous Resection, with or without Cartilage Scoring, Contouring or Replacement with Graft | CLAIM | 280 | $1,009.40 | $2,204.20 | $2,770.70 |
| CPT-42820 | Tonsillectomy and Adenoidectomy; Younger Than Age 12 (ASC Facility + Professional Global) | CLAIM | 325 | $865.20 | $1,874.60 | $2,358.70 |
| CPT-63030 | Neurosurgery & Spine: Lumbar Laminotomy/Discectomy (1 Interspace) & CPT 22551 Anterior Cervical ACDF | CLAIM | 185 | $1,480.00 | $2,190.00 | $2,940.00 |
| CPT-45380 | Gastroenterology & Endoscopy ASC: Flexible Colonoscopy with Biopsy & CPT 43239 Upper GI EGD | CLAIM | 610 | $520.00 | $795.00 | $1,140.00 |
| CPT-66984 | Ophthalmology & Ophthalmic ASC: Extracapsular Cataract Removal with IOL Prosthesis & CPT 67028 | CLAIM | 540 | $680.00 | $985.00 | $1,390.00 |
| CPT-52356 | Urology & Lithotripsy: Cystourethroscopy with Ureteroscopy, Lithotripsy & Indwelling Stent Insertion | CLAIM | 230 | $810.00 | $1,240.00 | $1,745.00 |
| CPT-70553 | Diagnostic Radiology & Cardiology: Brain MRI w/ & w/o Contrast, CPT 74177 CT & CPT 93306 Echo | CLAIM | 480 | $410.00 | $685.00 | $995.00 |
| CPT-99285 | Emergency Medicine, Pathology & Anesthesia: Level-5 E/M, CPT 88305 Surgical Path & CPT 01402 QPA | CLAIM | 890 | $340.00 | $565.00 | $845.00 |
2. Regional Peer Specialty Groups & EIN/NPI MRF Comparables (API #11)
CureMB Medical Billing ServicesIllinois Bone & Joint InstituteNeolytix HealthcareStreamline Healthcare