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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
VA
VABOI-MRF-CPT-99285-RIC
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Virginia Bureau of Insurance (SCC) & Palmetto GBA JM MRF Index — Northern VA / Richmond MSA
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Henrico County, VA
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Filing / IDR Window: 2026-11-25
[VABOI-MRF-CPT-99285-RIC] Anthem Blue Cross Blue Shield of Virginia TiC MRF Rate Disparity: Ophthalmology & Anterior Segment Cataract/MIGS ASC (CPT 66984)
Commercial payer TiC MRF negotiated rate benchmark and bilateral/MIGS multiple-procedure reduction (50% MPPR) audit for Virginia Ophthalmic Ambulatory Surgery Centers (CPT 66984 Extracapsular Cataract Extraction with IOL, CPT 66991 Cataract with Anterior Segment Aqueous Drainage Device, CPT 66821 YAG Laser Capsulotomy, and CPT 65855 Trabeculoplasty) across Blue Cross Blue Shield of Virginia & UnitedHealthcare.
Cohort MRF 75th-Pct Value
$1,485,000
Target % of Medicare
213.5% MPFS
Statutory Authority
VA-GPCI-2026-NOVA (Medicare Locality 00904-01 & VA Code § 38.2-3407.15 Prompt-Pay)
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-66984 | Extracapsular Cataract Removal with Insertion of Intraocular Lens Prosthesis (1 Stage, ASC Facility + Pro) | CLAIM | 625 | $778.15 | $1,615.40 | $2,029.10 |
| CPT-66991 | Extracapsular Cataract Removal with Insertion of IOL and Aqueous Drainage Assist Device (MIGS) | CLAIM | 230 | $1,457.80 | $3,073.20 | $3,831.65 |
| CPT-66821 | Discission of Secondary Membranous Cataract (Opacified Posterior Lens Capsule), Laser Surgery (YAG) | CLAIM | 435 | $261.02 | $531.90 | $674.73 |
| CPT-65855 | Trabeculoplasty by Laser Surgery (SLT Glaucoma Therapy, Single or Multiple Sessions) | CLAIM | 320 | $290.57 | $600.85 | $763.38 |
2. Regional Peer Specialty Groups & EIN/NPI MRF Comparables (API #11)
Advanced Sedation Dentistry - Hampton (NPI 1336585702)Advanced Health Care And Wellness Llc (NPI 1356186787)OrthoVirginia Outpatient Surgery CenterInova Fairfax Ambulatory Surgery CenterVirginia Cardiovascular Specialists PCTuckahoe Orthopaedics Surgery Center