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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
WY
WYDOI-MRF-CPT-99285-348
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Wyoming Department of Insurance (WDOI) & CMS TiC Payer MRF Index
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Laramie County, WY
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Filing / IDR Window: 2026-11-26
[WYDOI-MRF-CPT-99285-348] Blue Cross Blue Shield of Wyoming 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 Wy 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 Blue Cross Blue Shield of Wyoming & Cigna Mountain.
Cohort MRF 75th-Pct Value
$1,510,000
Target % of Medicare
215.0% MPFS
Statutory Authority
WY-GPCI-2026 (Wyo. Stat. § 26-15-124 (10% 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-99285 | Level 5 Emergency Department Visit (High Complexity) | CLAIM | 460 | $345.00 | $845.00 | $1,090.00 |
| CPT-00100 | Anesthesia for Salivary Gland / Complex Surgical Base + Time | CLAIM | 215 | $500.25 | $1,225.25 | $1,580.50 |
| 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)
Premier Bone & Joint Centers Laramie ASCWyoming Orthopedics & Spine SheridanTeton Orthopaedics Jackson Hole Surgery CenterPremier Bone & Joint CentersTeton Orthopedics Jackson