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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
OH
OHODI-MRF-CPT-52356-CMH
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Ohio Department of Insurance (ODI) & CGS J15 MRF Index — Columbus / Cleveland MSA
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Franklin County, OH
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Filing / IDR Window: 2026-12-02
[OHODI-MRF-CPT-52356-CMH] Anthem Blue Cross and Blue Shield of Ohio TiC MRF Rate Disparity: Spine & Neurosurgery Outpatient Decompression/Fusion (CPT 63030 / 22551)
Commercial payer TiC MRF negotiated rate percentile audit and ERISA 29 CFR 2560.503-1 clinical medical-necessity appeal cohort for Ohio 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 Blue Cross Blue Shield of Ohio & UnitedHealthcare.
Cohort MRF 75th-Pct Value
$1,920,000
Target % of Medicare
249.0% MPFS
Statutory Authority
OH-GPCI-2026-CMH (Medicare Locality 15202-00 & O.R.C. § 3901.389 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-63030 | Laminotomy (Hemilaminectomy), with Decompression of Nerve Root(s), Including Partial Facetectomy, Lumbar | CLAIM | 270 | $2,031.75 | $4,429.00 | $5,676.00 |
| CPT-22551 | Arthrodesis, Anterior Interbody, Including Disc Space Preparation, Discectomy, Osteophytectomy, Cervical Below C2 | CLAIM | 175 | $3,923.75 | $8,428.00 | $10,416.75 |
| CPT-63047 | Laminectomy, Facetectomy and Foraminotomy, Single Vertebral Segment; Lumbar | CLAIM | 225 | $2,311.25 | $4,934.25 | $6,170.50 |
| CPT-64483 | Injection(s), Anesthetic Agent and/or Steroid, Transforaminal Epidural, with Fluoroscopic Guidance; Lumbar/Sacral | CLAIM | 600 | $311.75 | $688.00 | $876.12 |
2. Regional Peer Specialty Groups & EIN/NPI MRF Comparables (API #11)
Orthopedic ONE Easton Surgery CenterCleveland Clinic Beachwood Ambulatory Surgery CenterBeacon Orthopaedics & Sports Medicine Summit Woods ASCOhioHealth Dublin Methodist Outpatient SurgeryUniversity Hospitals Amherst Beaver Creek ASC