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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
TX
TXDOI-MRF-CPT-88305
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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
TX Commercial Payer TiC MRF & Lab Reimbursement Cohort — CPT 88305 / 80053
Commercial payer TiC MRF negotiated rate audit, CMS Medicare MPFS RVU/GPCI locality repricing, and ERISA 29 CFR § 2560.503-1 / Federal No Surprises Act (45 CFR § 149.510) IDR arbitration package for Pathology & Clinical Laboratory in TX (CPT 88305 Level IV Surgical Pathology & Out-of-Network Lab Payer MRF Rates).
Cohort MRF 75th-Pct Value
$1,845,000
Target % of Medicare
228.5% MPFS
Statutory Authority
TX-GPCI-2026-DFW (Medicare Locality 04412-11 & TX Ins. Code § 1301.103 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 88305 | CPT 88305 Level IV Surgical Pathology & Out-of-Network Lab Payer MRF Rates | CLAIM | 420 | $940.00 | $1,485.00 | $2,140.00 |
| 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 |
2. Regional Peer Specialty Groups & EIN/NPI MRF Comparables (API #11)
Clinical Pathology LaboratoriesSonic Healthcare USA LaboratoryTX Regional Pathology Associates PA