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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
UT
UTDOI-MRF-CPT-93458-324
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Utah Insurance Department (UID) & CMS TiC Payer MRF Index
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Salt Lake County, UT
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Filing / IDR Window: 2026-11-22
[UTDOI-MRF-CPT-93458-324] Regence BlueCross BlueShield of Utah TiC MRF Rate Disparity: Gastroenterology & Ambulatory Endoscopy Center (CPT 45378 / 43239)
Commercial payer TiC MRF facility vs. professional rate spread audit and NCCI PTP Modifier 59/PT unbundling defense for Ut Gastroenterology Endoscopy centers (CPT 45378 Diagnostic Colonoscopy, CPT 45385 Colonoscopy with Snare Polypectomy, CPT 43239 Upper GI Endoscopy EGD with Biopsy, and CPT 00812 Screening Anesthesia) across SelectHealth & Regence BlueCross BlueShield of Utah.
Cohort MRF 75th-Pct Value
$1,705,000
Target % of Medicare
225.0% MPFS
Statutory Authority
UT-GPCI-2026 (Utah Code § 31A-26-301.6)
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-93458 | Left Heart Catheterization with Coronary Angiography | CLAIM | 460 | $1,073.80 | $2,493.40 | $3,112.20 |
| CPT-93306 | Transthoracic Echocardiography Complete with Doppler | CLAIM | 240 | $1,557.01 | $3,615.43 | $4,512.69 |
| CPT-99214-25 | Level 4 Established Patient Outpatient E/M with Separately Identifiable Modifier 25 | CLAIM | 1,200 | $115.00 | $172.00 | $204.00 |
2. Regional Peer Specialty Groups & EIN/NPI MRF Comparables (API #11)
The Orthopedic Specialty Hospital (TOSH) MurrayUniversity of Utah Health Farmington Surgery CenterRevere Health Provo Orthopedic ASCEmergency Physicians Integrated CareHoopes Vision