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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
PA
PAPID-MRF-CPT-66984-PHL
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Pennsylvania Insurance Department (PID) & Novitas JL MRF Index — Philadelphia MSA
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Montgomery County, PA
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Filing / IDR Window: 2026-11-26
[PAPID-MRF-CPT-66984-PHL] Highmark BCBS & Independence Blue Cross Ophthalmology / Cataract ASC MRF Rate Spread & Act 68 Prompt-Pay (CPT 66984 / 67028)
Commercial payer MRF negotiated rate benchmark and ERISA medical necessity appeal dossier for Ophthalmology & Retina Surgery Centers (CPT 66984 Extracapsular Cataract Removal with IOL Insertion, CPT 66821 YAG Laser Capsulotomy, and CPT 67028 Intravitreal Injection of Pharmacologic Agent with J0178 / J2778 Buy-and-Bill drug reimbursement).
Cohort MRF 75th-Pct Value
$1,420,000
Target % of Medicare
11.0% MPFS
Statutory Authority
PA-GPCI-2026-PHL (Medicare Locality 12502-01 & 40 P.S. § 991.2166 10% Prompt-Pay)
ERISA / Timely-Filing Window
350 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-66984 | Extracapsular Cataract Removal with Insertion of Intraocular Lens Prosthesis (ASC + Pro) | CLAIM | 780 | $820.00 | $1,740.00 | $2,190.00 |
| CPT-67028 | Intravitreal Injection of a Pharmacologic Agent (Separate Procedure + J-Code Audit) | CLAIM | 1,620 | $115.00 | $245.00 | $310.00 |
| CPT-66821 | Discission of Secondary Membranous Cataract (Posterior Capsulotomy), Laser Surgery | CLAIM | 410 | $260.00 | $530.00 | $670.00 |
2. Regional Peer Specialty Groups & EIN/NPI MRF Comparables (API #11)
Keystone Eye & Laser Surgery CenterDelaware Valley Retina Associates PCMain Line Ophthalmic Surgical InstituteAllegheny Ophthalmic & Cataract CenterPenn-Jersey Vision Surgery Partners