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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
NJ
NJDOI-MRF-CPT-45378-312
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New Jersey Department of Banking and Insurance (NJDOBI) & CMS TiC Payer MRF Index
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Middlesex County, NJ
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Filing / IDR Window: 2026-11-20
[NJDOI-MRF-CPT-45378-312] New Jersey UHC, Anthem & BCBS-NJ Commercial MRF Rate Disparity & NSA IDR Benchmark (CPT 45378 / 45380 GI Endoscopy & Colonoscopy ASC)
Commercial payer Transparency in Coverage (TiC) Machine-Readable File (MRF) negotiated rate audit and Federal No Surprises Act (NSA) IDR arbitration dossier for CPT 45378 / 45380 GI Endoscopy & Colonoscopy ASC in New Jersey (N.J.S.A. 17B:30-26 (12% Prompt-Pay)).
Cohort MRF 75th-Pct Value
$1,790,000
Target % of Medicare
212.0% MPFS
Statutory Authority
NJ-GPCI-2026 (N.J.S.A. 17B:30-26 (12% Prompt-Pay))
ERISA / Timely-Filing Window
470 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-45378 | Diagnostic Colonoscopy with Biopsy (ASC Facility + Pro) | CLAIM | 460 | $397.70 | $936.05 | $1,178.55 |
| CPT-43239 | Upper GI Endoscopy (EGD) with Biopsy | CLAIM | 190 | $576.66 | $1,357.27 | $1,708.90 |
| 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)
New Jersey Specialty Surgical AssociatesNew Jersey Ambulatory Surgery Center LLCRegional Medical Group of New JerseyNew Jersey Physician Billing & RCM Partners