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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
MT
MTDOI-MRF-CPT-63030-341
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Montana Commissioner of Securities and Insurance (CSI) & CMS TiC Payer MRF Index
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Yellowstone County, MT
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Filing / IDR Window: 2026-11-19
[MTDOI-MRF-CPT-63030-341] Mt Blue Cross and Blue Shield of Montana MRF Rate Disparity: Ophthalmology & Anterior Segment Cataract/MIGS ASC (CPT 66984)
Commercial payer TiC MRF negotiated rate benchmark and bilateral/MIGS multiple-procedure reduction (50% MPPR) audit for Mt Ophthalmic Ambulatory Surgery Centers (CPT 66984 Extracapsular Cataract Extraction with IOL, CPT 66991 Cataract with Anterior Segment Aqueous Drainage Device, CPT 66821 YAG Laser Capsulotomy, and CPT 65855 Trabeculoplasty) across Blue Cross and Blue Shield of Montana & PacificSource.
Cohort MRF 75th-Pct Value
$1,745,000
Target % of Medicare
208.5% MPFS
Statutory Authority
MT-GPCI-2026 (MCA § 33-18-232 (10% 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 | $1,820.00 | $4,290.00 | $5,420.00 |
| CPT-22551 | Anterior Cervical Discectomy & Interbody Fusion (ACDF) | CLAIM | 165 | $2,639.00 | $6,220.50 | $7,859.00 |
| 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)
Ortho Montana Yellowstone Surgery Center BillingsMissoula Bone & Joint Surgery CenterBozeman Health Bridger Orthopedic Pavilion