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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
ME
MEDOI-MRF-CPT-93458-339
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Maine Bureau of Insurance (BOI) & CMS TiC Payer MRF Index
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Cumberland County, ME
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Filing / IDR Window: 2026-11-27
[MEDOI-MRF-CPT-93458-339] Me Anthem Blue Cross Blue Shield ME MRF Rate Disparity: Spine & Neurosurgery Outpatient Decompression/Fusion (CPT 63030)
Commercial payer TiC MRF negotiated rate percentile audit and ERISA 29 CFR 2560.503-1 clinical medical-necessity appeal cohort for Me 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 Anthem Blue Cross Blue Shield ME & Community Health Options.
Cohort MRF 75th-Pct Value
$2,245,000
Target % of Medicare
259.0% MPFS
Statutory Authority
ME-GPCI-2026 (24-A M.R.S. § 2436 (18% 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-93458 | Left Heart Catheterization with Coronary Angiography | CLAIM | 580 | $1,109.20 | $2,575.60 | $3,214.80 |
| CPT-93306 | Transthoracic Echocardiography Complete with Doppler | CLAIM | 240 | $1,608.34 | $3,734.62 | $4,661.46 |
| 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)
Spectrum Healthcare Partners Portland Surgery CenterMaineGeneral Orthopaedics Augusta OutpatientNorthern Light Mercy Surgery Center Fore RiverInterMed