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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
VA
VABOI-MRF-CPT-99285-RIC
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Virginia Bureau of Insurance (SCC) & Palmetto GBA JM MRF Index — Northern VA / Richmond MSA
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Henrico County, VA
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Filing / IDR Window: 2026-11-25
[VABOI-MRF-CPT-99285-RIC] Anthem HealthKeepers & Cigna Emergency Medicine / Radiology Out-of-Network NSA IDR & Downcoding Audit (CPT 99285 / 74177)
Automated EDI 835 remittance advice downcoding audit (reversing unilateral commercial payer downcoding of Level 5 Emergency Department E/M CPT 99285 to CPT 99283/99284 in violation of the federal Prudent Layperson Standard) and Federal No Surprises Act (45 CFR 149.510) IDR arbitration brief for Emergency Medicine & Diagnostic Radiology groups in Virginia.
Cohort MRF 75th-Pct Value
$2,120,000
Target % of Medicare
12.0% MPFS
Statutory Authority
VA-GPCI-2026-NOVA (Medicare Locality 00904-01 & VA Code § 38.2-3407.15 Prompt-Pay)
ERISA / Timely-Filing Window
450 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 | Emergency Department Visit, High Severity & High Medical Decision Making (Prudent Layperson Defense) | CLAIM | 1,850 | $215.00 | $585.00 | $745.00 |
| CPT-99291 | Critical Care, Evaluation and Management of the Critically Ill or Critically Injured Patient; First 30-74 Min | CLAIM | 410 | $310.00 | $790.00 | $985.00 |
| CPT-74177 | CT Abdomen and Pelvis with Contrast Material(s) (26 Professional Component + TC) | CLAIM | 960 | $195.00 | $460.00 | $595.00 |
2. Regional Peer Specialty Groups & EIN/NPI MRF Comparables (API #11)
Advanced Sedation Dentistry - Hampton (NPI 1336585702)Advanced Health Care And Wellness Llc (NPI 1356186787)Commonwealth Emergency Physicians PCDominion Diagnostic Imaging AssociatesTidewater Acute Care SpecialistsShenandoah Valley Radiology Group