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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
KY
KYDOI-MRF-CPT-29881
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Kentucky Department of Insurance (KDOI) & CMS TiC Payer MRF Index
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Jefferson County, KY
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Filing / IDR Window: 2026-11-26
KY 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 KY (CPT 29881 Knee Arthroscopy & CPT 27447 Total Knee Arthroplasty).
Cohort MRF 75th-Pct Value
$1,450,000
Target % of Medicare
228.5% MPFS
Statutory Authority
KY-GPCI-2026 (KRS 304.17A-702 (12%–21% 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-99285 | Level 5 Emergency Department Visit (High Complexity) | CLAIM | 380 | $355.35 | $870.35 | $1,122.70 |
| CPT-00100 | Anesthesia for Salivary Gland / Complex Surgical Base + Time | CLAIM | 215 | $515.26 | $1,262.01 | $1,627.91 |
| 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)
Advantum HealthEllis & Badenhausen OrthopaedicsKY Regional Orthopedic Associates PA