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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
SD
SDDOI-MRF-CPT-99285-343
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South Dakota Division of Insurance (SD DOI) & CMS TiC Payer MRF Index
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Minnehaha County, SD
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Filing / IDR Window: 2026-11-21
[SDDOI-MRF-CPT-99285-343] Wellmark Blue Cross and Blue Shield of South Dakota TiC MRF Rate Disparity: Urology & Lithotripsy / Endourology Surgery Center (CPT 52356)
Commercial payer TiC MRF rate disparity audit and ERISA clinical appeal package for Sd Urology & Lithotripsy Ambulatory Surgery Centers (CPT 52356 Cystourethroscopy with Ureteroscopy, Laser Lithotripsy & Indwelling Stent, CPT 50590 Extracorporeal Shock Wave Lithotripsy ESWL, CPT 52000 Diagnostic Cystourethroscopy, and CPT 52601 Transurethral Electrosurgical Resection of Prostate TURP) across Wellmark Blue Cross Blue Shield SD & Sanford Health Plan.
Cohort MRF 75th-Pct Value
$1,340,000
Target % of Medicare
226.5% MPFS
Statutory Authority
SD-GPCI-2026 (SDCL § 58-12-20)
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-99285 | Level 5 Emergency Department Visit (High Complexity) | CLAIM | 500 | $365.70 | $895.70 | $1,155.40 |
| CPT-00100 | Anesthesia for Salivary Gland / Complex Surgical Base + Time | CLAIM | 215 | $530.26 | $1,298.77 | $1,675.33 |
| 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)
Orthopedic Institute Sioux Falls Surgery CenterBlack Hills Orthopedic & Spine Center Rapid CitySanford USD Medical Center Day Surgery