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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
PA
PADOI-MRF-CPT-88305
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Pennsylvania Insurance Department (PID) & Novitas JL MRF Index — Philadelphia MSA
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Montgomery County, PA
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Filing / IDR Window: 2026-11-26
PA Commercial Payer TiC MRF & Lab Reimbursement Cohort — CPT 88305 / 80053
Commercial payer TiC MRF negotiated rate audit, CMS Medicare MPFS RVU/GPCI locality repricing, and ERISA 29 CFR § 2560.503-1 / Federal No Surprises Act (45 CFR § 149.510) IDR arbitration package for Pathology & Clinical Laboratory in PA (CPT 88305 Level IV Surgical Pathology & Out-of-Network Lab Payer MRF Rates).
Cohort MRF 75th-Pct Value
$2,400,000
Target % of Medicare
262.0% MPFS
Statutory Authority
PA-GPCI-2026-PHL (Medicare Locality 12502-01 & 40 P.S. § 991.2166 10% Prompt-Pay)
ERISA / Timely-Filing Window
180 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 | Catheter Placement in Coronary Artery(s) for Coronary Angiography, Including Left Heart Catheterization | CLAIM | 350 | $1,420.00 | $3,180.00 | $3,990.00 |
| CPT-92928 | Percutaneous Transcatheter Placement of Intracoronary Stent(s), with Coronary Angioplasty; Single Major Artery | CLAIM | 205 | $3,890.00 | $8,420.00 | $10,650.00 |
| CPT-33249 | Insertion or Replacement of Permanent Implantable Defibrillator System, with Transvenous Lead(s) | CLAIM | 145 | $6,200.00 | $13,450.00 | $16,890.00 |
| CPT-93306 | Echocardiography, Transthoracic, Real-Time with Image Documentation (2D), Complete, with Spectral & Color Doppler | CLAIM | 780 | $195.00 | $445.00 | $570.00 |
| CPT-29881 | Orthopedic & ASC: Arthroscopy, Knee, Surgical; with Meniscectomy (Medial/Lateral) & CPT 27447 Total Knee | CLAIM | 420 | $640.00 | $1,185.00 | $1,495.00 |
| CPT-63030 | Neurosurgery & Spine: Lumbar Laminotomy/Discectomy (1 Interspace) & CPT 22551 Anterior Cervical ACDF | CLAIM | 185 | $1,480.00 | $2,190.00 | $2,940.00 |
| CPT-45380 | Gastroenterology & Endoscopy ASC: Flexible Colonoscopy with Biopsy & CPT 43239 Upper GI EGD | CLAIM | 610 | $520.00 | $795.00 | $1,140.00 |
| CPT-66984 | Ophthalmology & Ophthalmic ASC: Extracapsular Cataract Removal with IOL Prosthesis & CPT 67028 | CLAIM | 540 | $680.00 | $985.00 | $1,390.00 |
| CPT-52356 | Urology & Lithotripsy: Cystourethroscopy with Ureteroscopy, Lithotripsy & Indwelling Stent Insertion | CLAIM | 230 | $810.00 | $1,240.00 | $1,745.00 |
| CPT-70553 | Diagnostic Radiology & Cardiology: Brain MRI w/ & w/o Contrast, CPT 74177 CT & CPT 93306 Echo | CLAIM | 480 | $410.00 | $685.00 | $995.00 |
| CPT-99285 | Emergency Medicine, Pathology & Anesthesia: Level-5 E/M, CPT 88305 Surgical Path & CPT 01402 QPA | CLAIM | 890 | $340.00 | $565.00 | $845.00 |
2. Regional Peer Specialty Groups & EIN/NPI MRF Comparables (API #11)
HNL Lab MedicinePA Regional Pathology Associates PAPA Ambulatory Pathology Center LLC