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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
DE
DEDOI-MRF-CPT-45378-342
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Delaware Department of Insurance (DDOI) & CMS TiC Payer MRF Index
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New Castle County, DE
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Filing / IDR Window: 2026-11-20
[DEDOI-MRF-CPT-45378-342] Highmark Blue Cross Blue Shield Delaware TiC MRF Rate Disparity: Interventional Cardiology & Outpatient Cath/EP Lab (CPT 93458 / 92928)
Commercial payer TiC MRF negotiated rate audit and Federal No Surprises Act (NSA) IDR arbitration dossier for De Interventional Cardiology & Outpatient Cath Lab procedures (CPT 93458 Left Heart Catheterization with Coronary Angiography, CPT 92928 Percutaneous Transcatheter Coronary Stent Placement, CPT 33249 ICD Pulse Generator & Lead Insertion, and CPT 93306 Complete Transthoracic Echocardiography) across Highmark Blue Cross Blue Shield Delaware & Aetna.
Cohort MRF 75th-Pct Value
$2,660,000
Target % of Medicare
257.0% MPFS
Statutory Authority
DE-GPCI-2026 (18 Del. C. § 2304(16) (18% 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-45378 | Diagnostic Colonoscopy with Biopsy (ASC Facility + Pro) | CLAIM | 460 | $422.30 | $993.95 | $1,251.45 |
| CPT-43239 | Upper GI Endoscopy (EGD) with Biopsy | CLAIM | 190 | $612.34 | $1,441.23 | $1,814.60 |
| 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)
First State Orthopaedics Limestone Surgery CenterChristianaCare Center for Surgical OptimizationBayhealth Outpatient Center Smyrna24/7 Medical Billing ServicesMedisys Data Solutions Medical Billing