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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
MI
MIDOI-MRF-CPT-63030-311
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Michigan Department of Insurance and Financial Services (DIFS) & CMS TiC Payer MRF Index
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Oakland County, MI
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Filing / IDR Window: 2026-11-19
[MIDOI-MRF-CPT-63030-311] Blue Cross Blue Shield of Michigan (BCBSM) TiC MRF Rate Disparity: Urology & Lithotripsy / Endourology Surgery Center (CPT 52356)
Commercial payer TiC MRF rate disparity audit and ERISA clinical appeal package for Mi Urology & Lithotripsy Ambulatory Surgery Centers (CPT 52356 Cystourethroscopy with Ureteroscopy, Laser Lithotripsy & Indwelling Stent, CPT 50590 Extracorporeal Shock Wave Lithotripsy ESWL, CPT 52000 Diagnostic Cystourethroscopy, and CPT 52601 Transurethral Electrosurgical Resection of Prostate TURP) across Blue Cross Blue Shield of Michigan & Priority Health.
Cohort MRF 75th-Pct Value
$1,600,000
Target % of Medicare
234.0% MPFS
Statutory Authority
MI-GPCI-2026 (MCL 500.2006 (12% Prompt-Pay))
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 | 420 | $1,710.80 | $4,032.60 | $5,094.80 |
| CPT-22551 | Anterior Cervical Discectomy & Interbody Fusion (ACDF) | CLAIM | 165 | $2,480.66 | $5,847.27 | $7,387.46 |
| 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)
Michigan Orthopaedic Surgeons Beaumont ASCHenry Ford Macomb Ambulatory SurgeryCorewell Health Grand Rapids Surgical CenterAdvantage Health Saint Mary'S Medical GroupB.S. Bohra M.D. P.C