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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
NC
NCDOI-MRF-CPT-29881
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North Carolina Department of Insurance (NCDOI) & Palmetto GBA JM MRF Index — Charlotte / Raleigh MSA
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Mecklenburg County, NC
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Filing / IDR Window: 2026-12-01
NC Commercial Payer TiC MRF & Federal NSA IDR Cohort — Multi-Specialty RCM
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 Multi-Specialty Surgical, ASC & E/M in NC (CPT 29881 Arthroscopy, CPT 45380 Endoscopy & CPT 99285 High-Severity E/M).
Cohort MRF 75th-Pct Value
$1,985,000
Target % of Medicare
231.0% MPFS
Statutory Authority
NC-GPCI-2026-CLT (Medicare Locality 11502-00 & N.C.G.S. § 58-3-225 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-29881 | Knee Arthroscopy, Surgical, with Meniscectomy (Medial OR Lateral, ASC Facility + Pro) | CLAIM | 405 | $662.50 | $1,579.40 | $2,008.70 |
| CPT-29827 | Shoulder Arthroscopy, Surgical, with Rotator Cuff Repair (Modifier 59 / XU Audit) | CLAIM | 240 | $1,208.40 | $2,522.80 | $3,116.40 |
| CPT-27447 | Arthroplasty, Knee, Condyle and Plateau; Medial AND Lateral Compartments (Total Knee) | CLAIM | 140 | $5,035.00 | $9,911.00 | $12,497.40 |
| CPT-29888 | Arthroscopically Aided Anterior Cruciate Ligament (ACL) Repair/Augmentation/Reconstruction | CLAIM | 185 | $1,780.80 | $3,625.20 | $4,441.40 |
| CPT-63030 | Neurosurgery & Spine: Lumbar Laminotomy/Discectomy (1 Interspace) & CPT 22551 Anterior Cervical ACDF | CLAIM | 185 | $1,480.00 | $2,190.00 | $2,940.00 |
| CPT-45380 | Gastroenterology & Endoscopy ASC: Flexible Colonoscopy with Biopsy & CPT 43239 Upper GI EGD | CLAIM | 610 | $520.00 | $795.00 | $1,140.00 |
| CPT-66984 | Ophthalmology & Ophthalmic ASC: Extracapsular Cataract Removal with IOL Prosthesis & CPT 67028 | CLAIM | 540 | $680.00 | $985.00 | $1,390.00 |
| CPT-52356 | Urology & Lithotripsy: Cystourethroscopy with Ureteroscopy, Lithotripsy & Indwelling Stent Insertion | CLAIM | 230 | $810.00 | $1,240.00 | $1,745.00 |
| CPT-70553 | Diagnostic Radiology & Cardiology: Brain MRI w/ & w/o Contrast, CPT 74177 CT & CPT 93306 Echo | CLAIM | 480 | $410.00 | $685.00 | $995.00 |
| CPT-99285 | Emergency Medicine, Pathology & Anesthesia: Level-5 E/M, CPT 88305 Surgical Path & CPT 01402 QPA | CLAIM | 890 | $340.00 | $565.00 | $845.00 |
2. Regional Peer Specialty Groups & EIN/NPI MRF Comparables (API #11)
Bowling OrthopaedicsCape Fear Valley Health Medical GroupPinehurst Surgical ClinicRaleigh Orthopaedic Clinic