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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
KY
KYDOI-MRF-CPT-99285-328
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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
[KYDOI-MRF-CPT-99285-328] Ky Anthem Blue Cross Blue Shield KY 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 Ky 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 Anthem Blue Cross Blue Shield KY & Humana Commercial.
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)
Ellis & Badenhausen Orthopaedics Louisville ASCBluegrass Orthopaedics Lexington Surgery CenterBaptist Health Louisville Outpatient Surgical CenterAdvantum HealthEllis & Badenhausen Orthopaedics