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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
MA
MADOI-MRF-CPT-99285-313
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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
[MADOI-MRF-CPT-99285-313] Ma Blue Cross Blue Shield of Massachusetts MRF Rate Disparity: Interventional Pain Management & Neuromodulation ASC (CPT 63650)
Commercial payer TiC MRF implant device pass-through audit and ERISA 29 CFR 2560.503-1 prior-authorization denial appeal cohort for Ma Interventional Pain Management & Neuromodulation centers (CPT 63650 Percutaneous Spinal Cord Stimulator Lead Implantation, CPT 64635 Lumbar Medial Branch Radiofrequency Ablation, CPT 64493 Lumbar Facet Joint Injection, and CPT 62323 Lumbar Interlaminar Epidural) across Blue Cross Blue Shield of Massachusetts & Point32Health.
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 Out-Patient Surgical Suites (BOSS)Mass General Brigham Danvers Surgery CenterNew England Baptist Outpatient Care CenterBoston Vision ASCSeacoast Orthopedics & Sports Medicine