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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
TN
TNDOI-MRF-CPT-45378-317
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Tennessee Department of Commerce and Insurance (TDCI) & CMS TiC Payer MRF Index
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Davidson County, TN
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Filing / IDR Window: 2026-11-25
[TNDOI-MRF-CPT-45378-317] Tn BlueCross BlueShield of Tennessee MRF Rate Disparity: Ophthalmology & Anterior Segment Cataract/MIGS ASC (CPT 66984)
Commercial payer TiC MRF negotiated rate benchmark and bilateral/MIGS multiple-procedure reduction (50% MPPR) audit for Tn Ophthalmic Ambulatory Surgery Centers (CPT 66984 Extracapsular Cataract Extraction with IOL, CPT 66991 Cataract with Anterior Segment Aqueous Drainage Device, CPT 66821 YAG Laser Capsulotomy, and CPT 65855 Trabeculoplasty) across BlueCross BlueShield of Tennessee & Cigna South.
Cohort MRF 75th-Pct Value
$1,355,000
Target % of Medicare
218.5% MPFS
Statutory Authority
TN-GPCI-2026 (Tenn. Code Ann. § 56-7-109 (21% 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-45378 | Diagnostic Colonoscopy with Biopsy (ASC Facility + Pro) | CLAIM | 420 | $373.10 | $878.15 | $1,105.65 |
| CPT-43239 | Upper GI Endoscopy (EGD) with Biopsy | CLAIM | 190 | $541.00 | $1,273.32 | $1,603.19 |
| 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)
Campbell Clinic Surgery Center GermantownTennessee Orthopaedic Alliance (TOA) OneC1ty ASCVanderbilt Health Belle Meade Surgery CenterAmerican Esoteric LaboratoriesAmsurg