EFC - Medical Fee Benchmarking Data ( Actuarial Svcs )

2026-11-03

The Contractor shall utilize the most recent available edition of the National Council on Compensation Insurance ( NCCI ) Medical Data Report for the State of Idaho . 2 . DELIVERABLE 1 – INPATIENT HOSPITAL SERVICES ( MS - DRG ) The Contractor shall determine for each applicable MS - DRG code : • Average amount paid by commercial carriers in Idaho • Percentage of Medicare allowable represented by the average commercial payment • Payment amounts representing the 10th , 25th , 50th , 75th , and 90th percentiles for each MS - DRG code for inpatient services identified on page 26 of the National Council on Compensation Insurance ( NCCI ) Medical Data Report for the State of Idaho , September 2025 . If MS - DRG payments include implantable hardware , the Contractor shall identify the amount or percentage allocated for the implantable hardware , where available . If additional payments are allowed in excess of the MS - DRG payment , determine the average additional payment . If available data does not permit identifying these , amounts for device payments will be broken out separately , where available . All results shall be submitted in Microsoft Excel format . The report for this deliverable is due on May 29 , 2026 . 3 . DELIVERABLE 2 – HOSPITAL OUTPATIENT SERVICES ( CPT / APC ) The Contractor shall perform two analyses : Analysis A : Exclude all HCPCS codes with modifier - adjusted payments or bundling of charges to determine unadjusted reimbursement levels . Analysis B : Replicate NCCI methodology including modifiers , Place of Service , and specialty adjustments . The Contractor shall crosswalk CPT codes to APC codes to determine the average amount paid by commercial carriers in Idaho , the percentage of Medicare allowable that average represents , and the payment amounts representing the 10th , 25th , 50th , 75th , and 90th percentiles for each CPT code for hospital outpatient services identified on pages 33 , 35 , and 37 of the NCCI Medical Data Report for the State of Idaho , September 2025 . If the APC payment is inclusive of hardware , determine the amount or percentage allocated for the implantable hardware . If additional payments are allowed in excess of the APC payment , determine the average additional payment . If available data does not permit identifying these , amounts for device payments will be broken out separately , where available . Results shall be submitted in Microsoft Excel format . The report for this deliverable is due on May 29 , 2026 . 4 . DELIVERABLE 3 – PHYSICIAN PROFESSIONAL SERVICES The Contractor shall perform two analyses similar to Deliverable 2 for physician CPT codes . The Contractor shall calculate the average amount paid by commercial carriers in Idaho , the percentage of Medicare allowable that average represents , and the payment amounts representing the 10th , 25th , 50th , 75th , and 90th percentiles for each CPT code for physician professional services identified on pages 12 , 14 , 16 , 18 , and 20 of the NCCI Medical Data Report for the State of Idaho , September 2025 . Results shall be submitted in Microsoft Excel format .

Idaho

2026-05-06