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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
WV
WVDOI-MRF-CPT-45378-347
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West Virginia Offices of the Insurance Commissioner (WVOIC) & CMS TiC Payer MRF Index
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Kanawha County, WV
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Filing / IDR Window: 2026-11-25
[WVDOI-MRF-CPT-45378-347] Wv Highmark Blue Cross Blue Shield West Virginia MRF Rate Disparity: Spine & Neurosurgery Outpatient Decompression/Fusion (CPT 63030)
Commercial payer TiC MRF negotiated rate percentile audit and ERISA 29 CFR 2560.503-1 clinical medical-necessity appeal cohort for Wv Spine & Neurosurgery procedures (CPT 63030 Lumbar Laminotomy/Discectomy, CPT 22551 Anterior Cervical Discectomy & Fusion ACDF, CPT 63047 Lumbar Laminectomy, and CPT 64483 Transforaminal Epidural Injection) across Highmark Blue Cross Blue Shield West Virginia & Peak Health.
Cohort MRF 75th-Pct Value
$2,180,000
Target % of Medicare
244.0% MPFS
Statutory Authority
WV-GPCI-2026 (W. Va. Code § 33-45-2 (10% 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-45378 | Diagnostic Colonoscopy with Biopsy (ASC Facility + Pro) | CLAIM | 420 | $397.70 | $936.05 | $1,178.55 |
| CPT-43239 | Upper GI Endoscopy (EGD) with Biopsy | CLAIM | 190 | $576.66 | $1,357.27 | $1,708.90 |
| 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)
WVU Medicine Monongalia Outpatient Surgery CenterScott Orthopedic Center Huntington ASCCAMC Teays Valley Outpatient SurgeryScott Orthopedic Center WV