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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
NY
NYDFS-MRF-CPT-01402-NYC
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New York State Department of Financial Services (NYDFS) & NGS JK MRF Index — New York Metro MSA
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Nassau County, NY
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Filing / IDR Window: 2026-11-27
[NYDFS-MRF-CPT-01402-NYC] New York Blue Cross Blue Shield of New York MRF Rate Disparity: Urology & Lithotripsy / Endourology Surgery Center (CPT 52356)
Commercial payer TiC MRF rate disparity audit and ERISA clinical appeal package for New York 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 Blue Shield of New York & UnitedHealthcare.
Cohort MRF 75th-Pct Value
$1,665,000
Target % of Medicare
231.5% MPFS
Statutory Authority
NY-GPCI-2026-NYC (Medicare Locality 13202-01 & NY Ins. Law § 3224-a 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-52356 | Cystourethroscopy, with Ureteroscopy and/or Pyeloscopy; with Lithotripsy Including Insertion of Indwelling Ureteral Stent | CLAIM | 240 | $1,400.70 | $3,024.70 | $3,796.10 |
| CPT-50590 | Lithotripsy, Extracorporeal Shock Wave (ESWL) — Renal/Ureteral Calculus (ASC Facility + Professional) | CLAIM | 195 | $1,309.35 | $2,831.85 | $3,532.20 |
| CPT-52000 | Cystourethroscopy (Separate Procedure, Office/ASC Facility Fee & Modifier 25 E/M Unbundling Audit) | CLAIM | 510 | $248.67 | $537.95 | $685.12 |
| CPT-52601 | Transurethral Electrosurgical Resection of Prostate (TURP), Including Control of Postoperative Bleeding, Complete | CLAIM | 110 | $1,674.75 | $3,593.10 | $4,486.30 |
2. Regional Peer Specialty Groups & EIN/NPI MRF Comparables (API #11)
Hospital for Special Surgery (HSS) Manhattan ASCNYU Langone Ambulatory Care CenterNorthwell Health Syosset Surgery CenterMount Sinai Union Square Surgical CenterColumbiaDoctors Midtown Endoscopy & Surgery