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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
NJ
NJDOI-MRF-CPT-45378-312
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New Jersey Department of Banking and Insurance (NJDOBI) & CMS TiC Payer MRF Index
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Middlesex County, NJ
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Filing / IDR Window: 2026-11-20
[NJDOI-MRF-CPT-45378-312] Nj Horizon Blue Cross Blue Shield NJ 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 Nj 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 Horizon Blue Cross Blue Shield NJ & AmeriHealth.
Cohort MRF 75th-Pct Value
$1,580,000
Target % of Medicare
223.5% MPFS
Statutory Authority
NJ-GPCI-2026 (N.J.S.A. 17B:30-26 (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-45378 | Diagnostic Colonoscopy with Biopsy (ASC Facility + Pro) | CLAIM | 460 | $397.70 | $936.05 | $1,178.55 |
| CPT-43239 | Upper GI Endoscopy (EGD) with Biopsy | CLAIM | 190 | $576.66 | $1,357.27 | $1,708.90 |
| 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)
Rothman Orthopaedics Montvale Surgery CenterRWJBarnabas Health Livingston ASCHackensack Meridian Surgical CenterAllied Orthopaedics NJFlatworld Solutions