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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
NY
NYDFS-MRF-CPT-01402-NYC
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New York State Department of Financial Services (NYDFS) & NGS JK MRF Index — New York Metro MSA
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Nassau County, NY
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Filing / IDR Window: 2026-11-27
[NYDFS-MRF-CPT-01402-NYC] Empire BCBS, EmblemHealth & Oxford Anesthesiology / Plastic Reconstructive NSA IDR & NY ISC § 3224-a Prompt-Pay (CPT 01402 / 19318)
Federal No Surprises Act (45 CFR 149.510) and New York Financial Services Law Article 6 IDR arbitration position statement, commercial MRF conversion factor audit ($88–$142/anesthesia unit), and NY Insurance Law § 3224-a 12% statutory interest demand for Anesthesiology and Reconstructive Surgery groups in Downstate New York.
Cohort MRF 75th-Pct Value
$3,150,000
Target % of Medicare
16.5% MPFS
Statutory Authority
NY-GPCI-2026-NYC (Medicare Locality 13202-01 & NY Ins. Law § 3224-a 12% Prompt-Pay)
ERISA / Timely-Filing Window
720 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-01402 | Anesthesia for Total Knee Arthroplasty (Base Units + Time Units Conversion Factor Benchmark) | CLAIM | 620 | $520.00 | $1,480.00 | $1,920.00 |
| CPT-19318 | Breast Reduction / Reconstructive Mammaplasty (Bilateral Mod 50 & ERISA Medical Necessity) | CLAIM | 180 | $2,450.00 | $6,850.00 | $8,900.00 |
| CPT-19380 | Revision of Reconstructed Breast (WHCRA 29 U.S.C. § 1185b Federal Mandate Appeal) | CLAIM | 145 | $2,100.00 | $5,920.00 | $7,650.00 |
2. Regional Peer Specialty Groups & EIN/NPI MRF Comparables (API #11)
154 Northern Medical Practice (NPI 1710311691)128 Plastic Surgery Associates Pllc (NPI 1720381569)Metropolitan Anesthesia Partners LLPLong Island Reconstructive & Microsurgery PCTri-State Perioperative Medical AssociatesWestchester Surgical & Anesthesia Group