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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
RI
RIDOI-MRF-CPT-29881-340
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Rhode Island Department of Business Regulation — Insurance & CMS TiC Payer MRF Index
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Providence County, RI
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Filing / IDR Window: 2026-11-18
[RIDOI-MRF-CPT-29881-340] Blue Cross & Blue Shield of Rhode Island TiC MRF Rate Disparity: Gastroenterology & Ambulatory Endoscopy Center (CPT 45378 / 43239)
Commercial payer TiC MRF facility vs. professional rate spread audit and NCCI PTP Modifier 59/PT unbundling defense for Ri Gastroenterology Endoscopy centers (CPT 45378 Diagnostic Colonoscopy, CPT 45385 Colonoscopy with Snare Polypectomy, CPT 43239 Upper GI Endoscopy EGD with Biopsy, and CPT 00812 Screening Anesthesia) across Blue Cross & Blue Shield of Rhode Island & Tufts Health.
Cohort MRF 75th-Pct Value
$1,575,000
Target % of Medicare
212.5% MPFS
Statutory Authority
RI-GPCI-2026 (R.I. Gen. Laws § 27-18-61 (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-29881 | Knee Arthroscopy, Surgical, with Meniscectomy (ASC + Pro) | CLAIM | 380 | $620.80 | $1,445.30 | $1,823.60 |
| CPT-27447 | Total Knee Arthroplasty (Condyle and Plateau) | CLAIM | 140 | $900.16 | $2,095.68 | $2,644.22 |
| 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)
University Orthopedics Kettle Point Surgery CenterLifespan Miriam Hospital Outpatient SurgeryOrtho Rhode Island South County WakeField ASC