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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
MU
MUNICIPAL-ASC-RCM-2026-09
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Multi-State Self-Funded Municipal / Public Employee Health Plan & Commercial ASC Network Index
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Multi-State Regional MSA
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Filing / IDR Window: 2026-12-04
[MUNICIPAL-ASC-RCM-2026-09] Multi-Payer Commercial TiC MRF & ASC Facility Carve-Out Rate Disparity: Ophthalmology & Cataract/MIGS Surgery Center (CPT 66984)
Commercial payer TiC MRF negotiated rate benchmark and bilateral/MIGS multiple-procedure reduction (50% MPPR) audit for Municipal 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 Blue Shield of Municipal & UnitedHealthcare.
Cohort MRF 75th-Pct Value
$1,420,000
Target % of Medicare
216.0% MPFS
Statutory Authority
CMS-ASC-2026-REG (Medicare ASC Wage Index & 45 CFR § 149.610 Good Faith Estimate)
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-66984 | Extracapsular Cataract Removal with Insertion of Intraocular Lens Prosthesis (1 Stage, ASC Facility + Pro) | CLAIM | 595 | $742.60 | $1,541.60 | $1,936.40 |
| CPT-66991 | Extracapsular Cataract Removal with Insertion of IOL and Aqueous Drainage Assist Device (MIGS) | CLAIM | 200 | $1,391.20 | $2,932.80 | $3,656.60 |
| CPT-66821 | Discission of Secondary Membranous Cataract (Opacified Posterior Lens Capsule), Laser Surgery (YAG) | CLAIM | 405 | $249.10 | $507.60 | $643.90 |
| CPT-65855 | Trabeculoplasty by Laser Surgery (SLT Glaucoma Therapy, Single or Multiple Sessions) | CLAIM | 290 | $277.30 | $573.40 | $728.50 |
2. Regional Peer Specialty Groups & EIN/NPI MRF Comparables (API #11)
Summit Health Multi-State Specialty GroupPrivia Medical Group Regional Surgical PartnersOneGI National Gastroenterology AllianceHOPCo (Healthcare Outcomes Performance Co.) SpineUS Orthopaedic Partners Regional ASC Network