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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
IL
ILDOI-MRF-CPT-93458-CHI
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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
[ILDOI-MRF-CPT-93458-CHI] Illinois Blue Cross Blue Shield of Illinois MRF Rate Disparity: Otolaryngology (ENT) & Sinus Endoscopy Surgery Center (CPT 31255)
Commercial payer TiC MRF negotiated rate percentile audit and bilateral/multiple-endoscopy reduction defense for Illinois ENT & Sinus Surgery Centers (CPT 31255 Nasal/Sinus Endoscopy with Total Ethmoidectomy, CPT 31295 Balloon Sinus Ostial Dilation Maxillary, CPT 30520 Septoplasty, and CPT 42820 Tonsillectomy & Adenoidectomy) across Blue Cross Blue Shield of Illinois & UnitedHealthcare.
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-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 |
2. Regional Peer Specialty Groups & EIN/NPI MRF Comparables (API #11)
Midwest Orthopaedics at Rush Oak Brook ASCNorthwestern Medicine Outpatient Surgery CenterIllinois Bone & Joint Institute (IBJI) Morton Grove ASCDuPage Medical Group / Duly Health Surgery CenterAdvocate Good Shepherd Outpatient Center