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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
ND
NDDOI-MRF-CPT-93458-344
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North Dakota Insurance Department (NDID) & CMS TiC Payer MRF Index
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Cass County, ND
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Filing / IDR Window: 2026-11-22
[NDDOI-MRF-CPT-93458-344] Blue Cross Blue Shield of North Dakota TiC MRF Rate Disparity: Otolaryngology (ENT) & Sinus Endoscopy Surgery Center (CPT 31255)
Commercial payer TiC MRF negotiated rate percentile audit and bilateral/multiple-endoscopy reduction defense for Nd ENT & Sinus Surgery Centers (CPT 31255 Nasal/Sinus Endoscopy with Total Ethmoidectomy, CPT 31295 Balloon Sinus Ostial Dilation Maxillary, CPT 30520 Septoplasty, and CPT 42820 Tonsillectomy & Adenoidectomy) across Blue Cross Blue Shield of North Dakota & Sanford Health.
Cohort MRF 75th-Pct Value
$1,320,000
Target % of Medicare
233.5% MPFS
Statutory Authority
ND-GPCI-2026 (N.D.C.C. § 26.1-36-37.2)
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-93458 | Left Heart Catheterization with Coronary Angiography | CLAIM | 540 | $1,286.20 | $2,986.60 | $3,727.80 |
| CPT-93306 | Transthoracic Echocardiography Complete with Doppler | CLAIM | 240 | $1,864.99 | $4,330.57 | $5,405.31 |
| 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)
Bone & Joint Center Bismarck Surgery CenterSanford Broadway Medical Center Fargo ASCEssentia Health South University Clinic Surgery