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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
KS
KSDOI-MRF-CPT-63030-331
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Kansas Insurance Department (KID) & CMS TiC Payer MRF Index
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Johnson County, KS
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Filing / IDR Window: 2026-11-19
[KSDOI-MRF-CPT-63030-331] Blue Cross and Blue Shield of Kansas TiC MRF Rate Disparity: Spine & Neurosurgery Outpatient Decompression/Fusion (CPT 63030 / 22551)
Commercial payer TiC MRF negotiated rate percentile audit and ERISA 29 CFR 2560.503-1 clinical medical-necessity appeal cohort for Ks Spine & Neurosurgery procedures (CPT 63030 Lumbar Laminotomy/Discectomy, CPT 22551 Anterior Cervical Discectomy & Fusion ACDF, CPT 63047 Lumbar Laminectomy, and CPT 64483 Transforaminal Epidural Injection) across Blue Cross and Blue Shield of Kansas & Aetna.
Cohort MRF 75th-Pct Value
$2,310,000
Target % of Medicare
256.5% MPFS
Statutory Authority
KS-GPCI-2026 (K.S.A. 40-2442 (12% Prompt-Pay))
ERISA / Timely-Filing Window
180 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-63030 | Lumbar Laminotomy (Hemilaminectomy) with Decompression | CLAIM | 500 | $1,656.20 | $3,903.90 | $4,932.20 |
| CPT-22551 | Anterior Cervical Discectomy & Interbody Fusion (ACDF) | CLAIM | 165 | $2,401.49 | $5,660.65 | $7,151.69 |
| 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)
Kansas City Orthopaedic Institute (KCOI) LeawoodMid-America Orthopedics Wichita Surgery CenterKU MedWest Ambulatory Surgery CenterKansas City Orthopedic Alliance