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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
CT
CTDOI-MRF-CPT-99285-323
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Connecticut Insurance Department (CID) & CMS TiC Payer MRF Index
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Hartford County, CT
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Filing / IDR Window: 2026-11-21
[CTDOI-MRF-CPT-99285-323] Anthem Blue Cross and Blue Shield of Connecticut TiC MRF Rate Disparity: Spine & Neurosurgery Outpatient Decompression/Fusion (CPT 63030 / 22551)
Commercial payer TiC MRF negotiated rate percentile audit and ERISA 29 CFR 2560.503-1 clinical medical-necessity appeal cohort for Ct Spine & Neurosurgery procedures (CPT 63030 Lumbar Laminotomy/Discectomy, CPT 22551 Anterior Cervical Discectomy & Fusion ACDF, CPT 63047 Lumbar Laminectomy, and CPT 64483 Transforaminal Epidural Injection) across Anthem Blue Cross Blue Shield CT & ConnectiCare.
Cohort MRF 75th-Pct Value
$2,375,000
Target % of Medicare
254.0% MPFS
Statutory Authority
CT-GPCI-2026 (Conn. Gen. Stat. § 38a-816(15) (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-99285 | Level 5 Emergency Department Visit (High Complexity) | CLAIM | 420 | $376.05 | $921.05 | $1,188.10 |
| CPT-00100 | Anesthesia for Salivary Gland / Complex Surgical Base + Time | CLAIM | 215 | $545.27 | $1,335.52 | $1,722.74 |
| 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)
Orthopedic Associates of Hartford Rocky Hill ASCHartford HealthCare Bone & Joint InstituteYale New Haven Health Long Wharf Surgery CenterConnecticut Orthopaedics