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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
VT
VTDOI-MRF-CPT-63030-346
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Vermont Department of Financial Regulation (DFR) & CMS TiC Payer MRF Index
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Chittenden County, VT
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Filing / IDR Window: 2026-11-24
[VTDOI-MRF-CPT-63030-346] Vt Blue Cross and Blue Shield of Vermont MRF Rate Disparity: Orthopedic Sports Medicine & Knee/Shoulder ASC (CPT 29881)
Commercial payer Transparency in Coverage (TiC) Machine-Readable File (MRF) rate audit and Federal No Surprises Act (NSA) IDR arbitration dossier for Vt Orthopedic & ASC surgical claims (CPT 29881 Knee Arthroscopy Meniscectomy, CPT 29827 Arthroscopic Rotator Cuff Repair, CPT 27447 Total Knee Arthroplasty, and CPT 29888 ACL Reconstruction) across Blue Cross and Blue Shield of Vermont & MVP Health Care.
Cohort MRF 75th-Pct Value
$1,660,000
Target % of Medicare
243.5% MPFS
Statutory Authority
VT-GPCI-2026 (18 V.S.A. § 9418 (12% 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-63030 | Lumbar Laminotomy (Hemilaminectomy) with Decompression | CLAIM | 380 | $1,710.80 | $4,032.60 | $5,094.80 |
| CPT-22551 | Anterior Cervical Discectomy & Interbody Fusion (ACDF) | CLAIM | 165 | $2,480.66 | $5,847.27 | $7,387.46 |
| 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)
Mansfield Orthopaedics Waterbury & MorrisvilleUVM Medical Center Fanny Allen Outpatient SurgeryRutland Regional Orthopaedic & Sports Medicine