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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
ID
IDDOI-MRF-CPT-63030-336
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Idaho Department of Insurance (IDOI) & CMS TiC Payer MRF Index
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Ada County, ID
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Filing / IDR Window: 2026-11-24
[IDDOI-MRF-CPT-63030-336] Id Blue Cross of Idaho 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 Id 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 Blue Cross of Idaho & Regence BlueShield of Idaho.
Cohort MRF 75th-Pct Value
$1,385,000
Target % of Medicare
231.0% MPFS
Statutory Authority
ID-GPCI-2026 (Idaho Code § 28-22-104)
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-63030 | Lumbar Laminotomy (Hemilaminectomy) with Decompression | CLAIM | 460 | $1,929.20 | $4,547.40 | $5,745.20 |
| CPT-22551 | Anterior Cervical Discectomy & Interbody Fusion (ACDF) | CLAIM | 165 | $2,797.34 | $6,593.73 | $8,330.54 |
| 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)
Idaho Sports Medicine Institute Boise ASCSt. Luke's Orthopedic & Specialty Center MeridianBlackrock Orthopedics Eagle Surgery Center