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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
NE
NEDOI-MRF-CPT-29881-335
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Nebraska Department of Insurance (NDOI) & CMS TiC Payer MRF Index
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Douglas County, NE
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Filing / IDR Window: 2026-11-23
[NEDOI-MRF-CPT-29881-335] Blue Cross and Blue Shield of Nebraska TiC MRF Rate Disparity: Urology & Lithotripsy / Endourology Surgery Center (CPT 52356)
Commercial payer TiC MRF rate disparity audit and ERISA clinical appeal package for Ne Urology & Lithotripsy Ambulatory Surgery Centers (CPT 52356 Cystourethroscopy with Ureteroscopy, Laser Lithotripsy & Indwelling Stent, CPT 50590 Extracorporeal Shock Wave Lithotripsy ESWL, CPT 52000 Diagnostic Cystourethroscopy, and CPT 52601 Transurethral Electrosurgical Resection of Prostate TURP) across Blue Cross and Blue Shield of Nebraska & Medica.
Cohort MRF 75th-Pct Value
$1,405,000
Target % of Medicare
224.0% MPFS
Statutory Authority
NE-GPCI-2026 (Neb. Rev. Stat. § 44-8004 (12% 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-29881 | Knee Arthroscopy, Surgical, with Meniscectomy (ASC + Pro) | CLAIM | 420 | $659.20 | $1,534.70 | $1,936.40 |
| CPT-27447 | Total Knee Arthroplasty (Condyle and Plateau) | CLAIM | 140 | $955.84 | $2,225.32 | $2,807.78 |
| 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)
OrthoNebraska Oakview Surgery Center OmahaNebraska Orthopaedic Center Lincoln ASCCHI Health Lakeside Ambulatory Surgery