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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
MA
MADOI-MRF-CPT-66984
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Massachusetts Division of Insurance (MA DOI) & CMS TiC Payer MRF Index
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Middlesex County, MA
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Filing / IDR Window: 2026-11-21
MA Commercial Payer TiC MRF & ASC Facility Cohort — CPT 66984 / 67028 Ophthalmology
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 Ophthalmology & Ophthalmic ASC in MA (CPT 66984 Cataract Extraction with IOL & CPT 67028 Intravitreal Injection).
Cohort MRF 75th-Pct Value
$1,980,000
Target % of Medicare
236.5% MPFS
Statutory Authority
MA-GPCI-2026 (M.G.L. c. 176G § 6 & c. 175 § 110)
ERISA / Timely-Filing Window
90 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 | 500 | $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)
Boston Vision ASCMA Regional Ophthalmology Associates PAMA Ambulatory Ophthalmology Center LLC