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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
TX
TXDOI-MRF-CPT-29881-DFW
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Texas Department of Insurance (TDI) & CMS Novitas JH Payer MRF Index — Dallas-Fort Worth MSA
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Travis County, TX
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Filing / IDR Window: 2026-11-18
[TXDOI-MRF-CPT-29881-DFW] UHC & BCBS-TX Commercial MRF Rate Disparity, ASC Facility Fee & NSA IDR Benchmark (CPT 29881 / 27447 Orthopedic Surgery)
Commercial payer Transparency in Coverage (TiC) Machine-Readable File (MRF) rate audit and Federal No Surprises Act (NSA) IDR arbitration dossier for Orthopedic & ASC surgical procedures (CPT 29881 Knee Arthroscopy Meniscectomy, CPT 27447 Total Knee Arthroplasty, CPT 29827 Rotator Cuff Repair, and CPT 64483 Transforaminal Epidural Steroid Injection) across UnitedHealthcare, BCBS-TX, Aetna, and Cigna in Texas.
Cohort MRF 75th-Pct Value
$1,845,000
Target % of Medicare
14.5% MPFS
Statutory Authority
TX-GPCI-2026-DFW (Medicare Locality 04412-11 & TX Ins. Code § 1301.103 18% Prompt-Pay)
ERISA / Timely-Filing Window
420 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 (Medial OR Lateral, ASC Facility + Pro) | CLAIM | 420 | $640.00 | $1,485.00 | $1,890.00 |
| CPT-27447 | Arthroplasty, Knee, Condyle and Plateau; Medial AND Lateral Compartments (Total Knee) | CLAIM | 115 | $4,850.00 | $9,420.00 | $11,850.00 |
| CPT-29827 | Shoulder Arthroscopy, Surgical, with Rotator Cuff Repair (Modifier 59 / XU Audit) | CLAIM | 210 | $1,120.00 | $2,340.00 | $2,890.00 |
| CPT-64483 | Transforaminal Epidural Injection, Lumbar or Sacral, Single Level (Fluoroscopic Guidance) | CLAIM | 680 | $285.00 | $615.00 | $780.00 |
| CPT-99214-25 | Level 4 Established Patient Office/Outpatient E/M with Significant Separately Identifiable Mod 25 | CLAIM | 1,450 | $118.00 | $176.00 | $208.00 |
2. Regional Peer Specialty Groups & EIN/NPI MRF Comparables (API #11)
Texas Orthopedic Specialists PABaylor Scott & White SurgicareLonestar Ambulatory Surgery Center LLCAustin Spine & Neurosurgery AssociatesMethodist Orthopedic Surgical Group