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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
CA
CADOI-MRF-CPT-29881
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California Department of Managed Health Care (DMHC) & Noridian JE MRF Index — Bay Area MSA
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San Mateo County, CA
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Filing / IDR Window: 2026-11-20
CA Commercial Payer TiC MRF & NSA IDR Cohort — CPT 29881 / 27447 Orthopedic & ASC
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 Orthopedic & ASC Surgery in CA (CPT 29881 Knee Arthroscopy & CPT 27447 Total Knee Arthroplasty).
Cohort MRF 75th-Pct Value
$1,985,000
Target % of Medicare
246.5% MPFS
Statutory Authority
CA-GPCI-2026-SFO (Medicare Locality 01112-07 & CA Health & Safety § 1371 15% 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-29881 | Orthopedic & ASC: Arthroscopy, Knee, Surgical; with Meniscectomy (Medial/Lateral) & CPT 27447 Total Knee | CLAIM | 420 | $640.00 | $1,185.00 | $1,495.00 |
| CPT-63030 | Laminotomy (Hemilaminectomy), with Decompression of Nerve Root(s), Including Partial Facetectomy, Lumbar | CLAIM | 225 | $1,804.95 | $3,934.60 | $5,042.40 |
| CPT-22551 | Arthrodesis, Anterior Interbody, Including Disc Space Preparation, Discectomy, Osteophytectomy, Cervical Below C2 | CLAIM | 130 | $3,485.75 | $7,487.20 | $9,253.95 |
| CPT-63047 | Laminectomy, Facetectomy and Foraminotomy, Single Vertebral Segment; Lumbar | CLAIM | 180 | $2,053.25 | $4,383.45 | $5,481.70 |
| CPT-64483 | Injection(s), Anesthetic Agent and/or Steroid, Transforaminal Epidural, with Fluoroscopic Guidance; Lumbar/Sacral | CLAIM | 555 | $276.95 | $611.20 | $778.32 |
| CPT-45380 | Gastroenterology & Endoscopy ASC: Flexible Colonoscopy with Biopsy & CPT 43239 Upper GI EGD | CLAIM | 610 | $520.00 | $795.00 | $1,140.00 |
| CPT-66984 | Ophthalmology & Ophthalmic ASC: Extracapsular Cataract Removal with IOL Prosthesis & CPT 67028 | CLAIM | 540 | $680.00 | $985.00 | $1,390.00 |
| CPT-52356 | Urology & Lithotripsy: Cystourethroscopy with Ureteroscopy, Lithotripsy & Indwelling Stent Insertion | CLAIM | 230 | $810.00 | $1,240.00 | $1,745.00 |
| CPT-70553 | Diagnostic Radiology & Cardiology: Brain MRI w/ & w/o Contrast, CPT 74177 CT & CPT 93306 Echo | CLAIM | 480 | $410.00 | $685.00 | $995.00 |
| CPT-99285 | Emergency Medicine, Pathology & Anesthesia: Level-5 E/M, CPT 88305 Surgical Path & CPT 01402 QPA | CLAIM | 890 | $340.00 | $565.00 | $845.00 |
2. Regional Peer Specialty Groups & EIN/NPI MRF Comparables (API #11)
Alleva Healthcare BillingAllzone Management ServicesAnnexMed Medical BillingBikham Healthcare