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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
PA
PAPID-MRF-CPT-66984-PHL
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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
[PAPID-MRF-CPT-66984-PHL] Independence Blue Cross & Highmark BCBS Pennsylvania TiC MRF Rate Disparity: Interventional Cardiology & Outpatient Cath/EP Lab (CPT 93458 / 92928)
Commercial payer TiC MRF negotiated rate audit and Federal No Surprises Act (NSA) IDR arbitration dossier for Pennsylvania Interventional Cardiology & Outpatient Cath Lab procedures (CPT 93458 Left Heart Catheterization with Coronary Angiography, CPT 92928 Percutaneous Transcatheter Coronary Stent Placement, CPT 33249 ICD Pulse Generator & Lead Insertion, and CPT 93306 Complete Transthoracic Echocardiography) across Blue Cross Blue Shield of Pennsylvania & UnitedHealthcare.
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 |
2. Regional Peer Specialty Groups & EIN/NPI MRF Comparables (API #11)
325 Asc, Llc (NPI 1952785438)20-20 Surgery Center Llc (NPI 1194718940)Rothman Orthopaedic Specialty HospitalUPMC St. Margaret Harmar Outpatient CenterMain Line Health Surgery Center at WynnewoodAllegheny Health Network Monroeville ASC