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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
WI
WIDOI-MRF-CPT-29881-320
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Wisconsin Office of the Commissioner of Insurance (OCI) & CMS TiC Payer MRF Index
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Milwaukee County, WI
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Filing / IDR Window: 2026-11-18
[WIDOI-MRF-CPT-29881-320] Anthem Blue Cross and Blue Shield of Wisconsin TiC MRF Rate Disparity: Otolaryngology (ENT) & Sinus Endoscopy Surgery Center (CPT 31255)
Commercial payer TiC MRF negotiated rate percentile audit and bilateral/multiple-endoscopy reduction defense for Wi ENT & Sinus Surgery Centers (CPT 31255 Nasal/Sinus Endoscopy with Total Ethmoidectomy, CPT 31295 Balloon Sinus Ostial Dilation Maxillary, CPT 30520 Septoplasty, and CPT 42820 Tonsillectomy & Adenoidectomy) across Anthem Blue Cross Blue Shield WI & Dean Health Plan.
Cohort MRF 75th-Pct Value
$1,515,000
Target % of Medicare
226.0% MPFS
Statutory Authority
WI-GPCI-2026 (Wis. Stat. § 628.46 (7.5% 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-29881 | Knee Arthroscopy, Surgical, with Meniscectomy (ASC + Pro) | CLAIM | 540 | $640.00 | $1,490.00 | $1,880.00 |
| CPT-27447 | Total Knee Arthroplasty (Condyle and Plateau) | CLAIM | 140 | $928.00 | $2,160.50 | $2,726.00 |
| 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)
Orthopaedic Associates of Wisconsin Pewaukee ASCFroedtert & MCW Drexel Town Square Surgery CenterUW Health East Madison Hospital ASCOrthopedic Associates of Wisconsin