Appendix_C_(6-_Embassy_Egypt_CS_Claims_Analysis__11NOV2018_through_30APR2019).pdf
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Appendix C (6- Embassy Egypt CS Claims Analysis__11NOV2018 through 30APR2019)
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CS Claims Analysis by Client and Sub office Client code: 0312* Paid date from : 2018-11-1 to : 2019-4-30
Claims Paid by Benefit Category
Client / Suboffice Inpatient Outpatient Op Medication
Maternity Dental Optical Other Services
Total % of Total
0312A 001 AMERICAN EMBASSY 1,803,099 1,541,558 2,263,267 48,034 124,297 60,514 5,840,770 35% 0312B 001 AMERICAN EMBASSY 2,122,923 2,330,653 2,030,794 248,874 195,223 92,239 22,980 7,043,686 42%
0312C 001 AMERICAN EMBASSY 465,638 130,958 347,839 390 1,440 946,265 6%
0312D 001 AMERICAN EMBASSY 96,896 81,277 151,491 8,564 5,710 343,938 2%
0312E 001 AMERICAN EMBASSY 318,663 160,487 192,085 15,638 13,083 8,570 708,526 4%
0312H 001 AMERICAN EMBASSY 7,955 20,013 10,829 2,793 875 42,464 0%
0312I 001 AMERICAN EMBASSY USAID 209,254 197,567 136,145 12,063 20,915 5,430 581,374 3% 0312J 001 AMERICAN EMBASSY USAID 638,948 130,534 122,488 1,337 14,592 9,473 2,175 919,546 5%
0312F 001 AMERICAN EMBASSY 77,976 36,018 32,418 146,412 1%
0312G 001 AMERICAN EMBASSY 45,022 11,840 29,674 1,600 88,137 1%
0312K 001 AMERICAN EMBASSY 203,640 4,894 9,255 217,789 1%
Total 5,990,013 4,645,798 5,326,286 325,947 379,856 185,851 25,155 16,878,906 100%
Inpatient 35%
Outpati...
28%
Op Medication 32%
Maternity 2%
Dental 2%
Optical 1%
Other Ser...
0%
Inpatient 35%
Outpati...
28%
Op Medication 32%
Maternity 2%
Dental 2%
Optical 1%
Other Ser...
0%
PercentagePaid_usd
Inpatient Outpatient Op Medication Maternity Dental Optical Other Services
Cash vs. PPO Claims
Client / Suboffice CASH PPO Total % of Total
0312A 001 AMERICAN EMBASSY 166,651 5,674,119 5,840,770 35%
0312B 001 AMERICAN EMBASSY 402,138 6,641,547 7,043,686 42%
0312C 001 AMERICAN EMBASSY 14,162 932,103 946,265 6%
0312D 001 AMERICAN EMBASSY 8,624 335,314 343,938 2%
0312E 001 AMERICAN EMBASSY 23,009 685,517 708,526 4%
0312F 001 AMERICAN EMBASSY 13,835 132,576 146,412 1%
0312G 001 AMERICAN EMBASSY 910 87,227 88,137 1%
0312H 001 AMERICAN EMBASSY 898 41,566 42,464 0%
0312I 001 AMERICAN EMBASSY USAID 45,543 535,831 581,374 3%
0312J 001 AMERICAN EMBASSY USAID 54,576 864,970 919,546 5%
0312K 001 AMERICAN EMBASSY 16,310 201,479 217,789 1%
Total 746,657 16,132,249 16,878,906 100%
CASH
4%
PPO
96%
CASH
4%
PPO
96%
CASH
PPO
User: Maged Hamdy 1 of 12 May 5, 2019 4:40:56 PM
Paid date from : 2018-11-1 to : 2019-4-30
Cash Claims by Benefit Category
Client / Suboffice Inpatient Outpatient Op Medication
Maternity Dental Optical Other Services
Total % of Total
0312A 001 AMERICAN EMBASSY 30,849 23,446 32,860 60,530 18,966 166,651 22%
0312B 001 AMERICAN EMBASSY 55,155 99,341 16,975 87,850 101,492 18,344 22,980 402,138 54%
0312D 001 AMERICAN EMBASSY 350 5,874 2,400 8,624 1%
0312E 001 AMERICAN EMBASSY 2,082 1,296 6,500 9,540 3,590 23,009 3%
0312I 001 AMERICAN EMBASSY USAID 17,977 6,578 634 17,955 2,400 45,543 6%
0312J 001 AMERICAN EMBASSY USAID 5,383 19,382 9,738 800 12,036 5,062 2,175 54,576 7%
0312K 001 AMERICAN EMBASSY 3,640 4,830 7,840 16,310 2%
0312C 001 AMERICAN EMBASSY 13,254 107 800 14,162 2%
0312F 001 AMERICAN EMBASSY 738 13,097 13,835 2%
0312G 001 AMERICAN EMBASSY 28 82 800 910 0%
0312H 001 AMERICAN EMBASSY 98 800 898 0%
Total 64,178 188,931 79,160 128,644 207,427 53,163 25,155 746,657 100%
Inpatient 9%
Outpatient 25%
Op Medication 11%
Maternity 17%
Dental 28%
Optical 7%
Other Ser...
3%
Inpatient 9%
Outpatient 25%
Op Medication 11%
Maternity 17%
Dental 28%
Optical 7%
Other Ser...
3%
Op Medication Maternity Dental Optical Other Services
PPO Claims by Benefit Category
Client / Suboffice Inpatient Outpatient Op Medication
Maternity Dental Optical Other Services
Total % of Total
0312A 001 AMERICAN EMBASSY 1,803,099 1,510,709 2,239,821 15,174 63,767 41,548 5,674,119 35% 0312B 001 AMERICAN EMBASSY 2,067,768 2,231,312 2,013,819 161,024 93,730 73,894 0 6,641,547 41%
0312C 001 AMERICAN EMBASSY 465,638 117,703 347,732 390 640 932,103 6%
0312D 001 AMERICAN EMBASSY 96,896 80,927 151,491 2,690 3,310 335,314 2%
0312E 001 AMERICAN EMBASSY 318,663 158,404 190,789 9,138 3,543 4,980 685,517 4%
0312H 001 AMERICAN EMBASSY 7,955 19,915 10,829 2,793 75 41,566 0%
0312I 001 AMERICAN EMBASSY USAID 209,254 179,591 129,567 11,430 2,960 3,030 535,831 3% 0312J 001 AMERICAN EMBASSY USAID 633,565 111,152 112,750 537 2,556 4,410 864,970 5%
0312F 001 AMERICAN EMBASSY 77,976 35,279 19,321 132,576 1%
0312G 001 AMERICAN EMBASSY 45,022 11,812 29,592 800 87,227 1%
0312K 001 AMERICAN EMBASSY 200,000 64 1,415 201,479 1%
Total 5,925,835 4,456,867 5,247,126 197,303 172,429 132,688 0 16,132,249 100%
Inpatient 37%
Outpati...
28%
Op Medication 33%
Maternity 1%
Dental 1%
Optical 1%
Inpatient 37%
Outpati...
28%
Op Medication 33%
Maternity 1%
Dental 1%
Optical 1%
Op Medication Maternity Dental Optical Other Services
User: Maged Hamdy 2 of 12 May 5, 2019 4:40:56 PM
Paid date from : 2018-11-1 to : 2019-4-30
Monthly Claims Paid Amount
Year- Month
Inpatient Outpatient Op Medication
Maternity Dental Optical Other Services
Total
Nov-2018 828,702 885,309 802,097 52,936 65,324 21,531 2,520 2,658,418 Dec-2018 922,874 885,469 898,166 88,793 55,893 37,514 2,520 2,891,229 Jan-2019 959,770 754,828 955,617 46,709 37,781 14,608 2,520 2,771,833 Feb-2019 681,643 750,457 742,660 60,669 83,310 41,350 6,224 2,366,313 Mar-2019 1,455,747 756,494 1,124,366 31,880 78,473 29,366 4,836 3,481,162 Apr-2019 1,141,276 613,241 803,379 44,961 59,076 41,482 6,535 2,709,950 Total 5,990,013 4,645,798 5,326,286 325,947 379,856 185,851 25,155 16,878,906
500,000
1,000,000
1,500,000
2,000,000
2,500,000
3,000,000
3,500,000
4,000,000
Nov-2018 Dec-2018 Jan-2019 Feb-2019 Mar-2019 Apr-2019
Benefit_Category Inpatient Outpatient Op Medication Maternity Dental Optical Other Services
Year-Month
Pa id
_u sd
Monthly Claims Count
Year-Month Inpatient Outpatient Op Medication Maternity Dental Optical Other Services Nov-2018 64 2,806 2,998 68 129 49 2 Dec-2018 61 3,121 3,413 87 131 96 2 Jan-2019 58 2,668 3,638 64 89 24 4 Feb-2019 56 2,713 2,620 63 166 63 8 Mar-2019 59 2,402 3,745 49 140 50 8 Apr-2019 65 2,040 2,729 41 109 72 12 Total 363 15,750 19,143 372 764 354 36
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
Nov-2018 Dec-2018 Jan-2019 Feb-2019 Mar-2019 Apr-2019
Benefit_Category Inpatient Outpatient Op Medication Maternity Dental Optical Other Services
Year-Month
Cl ai m _c ou nt
User: Maged Hamdy 3 of 12 May 5, 2019 4:40:56 PM
Paid date from : 2018-11-1 to : 2019-4-30
Claims based on Paid Amount Range
Paid Amount Range No.of claims %of total claims Paid Amount % of Total
<= 250 25,247 69% 2,816,337 17%
251-500 5,449 15% 1,939,806 11%
501-1000 4,050 11% 2,905,394 17%
1001-2500 1,167 3% 1,701,496 10%
2501-5000 241 1% 861,511 5%
5001-10000 178 0% 1,251,839 7%
>=10000 174 0% 5,402,522 32%
Total 36,506 100% 16,878,906 100%
Top 10 Daignosis Codes based on Paid Amount
Top 10 Diagnosis Number of Claimant
Paid Amount % to Total
DIABETES MELLITUS (DM) 408 1,064,912 6%
HYPERTENSION 469 663,916 4%
ISCHEMIC HEART DISEASE (IHD) 120 540,580 3%
LUMBAGO / LOW BACK PAIN 776 477,674 3%
OSTEOARTHRITIS 377 472,511 3%
RESPIRATORY DISTRESS SYNDROME 4 443,114 3%
DENTAL 618 384,013 2%
BRONCHITIS, ACUTE 987 351,769 2%
INTERVERTEBRAL DISC 177 331,615 2%
BRONCHIAL ASTHMA 344 331,292 2%
Top 10 5,061,395 30%
Others 11,817,510 70%
Summary 16,878,906 100%
User: Maged Hamdy 4 of 12 May 5, 2019 4:40:56 PM
Paid date from : 2018-11-1 to : 2019-4-30
Top 10 Claimant based on Paid Amount
Top 10 Claimant
Paid Amount % of Total
Major Conditions
1 212,244 1% ABDOMINAL PAIN
ALLERGIC RHINITIS / RHINORRHEA / HAY FEVER
ASTHMATIC BRONCHITIS
BACK PAIN
BRONCHIAL ASTHMA
BRONCHITIS, ACUTE
CANDIDIASIS / YEAST INFECTION, UNSPECIFIC SITE
CHEST PAIN (UNSPECIFIC REASON)
DERMATITIS (& CONTACT) / ECZEMA
DIABETES MELLITUS (DM)
GASTRITIS
HYPERTENSION
IRRITABLE COLON / IRRITABLE BOWEL SYNDROME (IBS)
ISCHEMIC HEART DISEASE (IHD)
LUMBAGO / LOW BACK PAIN
NECK PAIN / CERVICALGIA
OSTEOARTHRITIS
OTHER SPECIFIED GENERAL MEDICAL EXAMINATIONS
OTITIS EXTERNA / EXTERNAL EAR ABSCESS
REFLUX ESOPHAGITIS
SINUSITIS, ACUTE
VASCULAR COMPLICATIONS OF MESENTERIC ARTERY
VENOUS THROMBOSIS / DEEP VENOUS THROMBOSIS (DVT)
WARTS / VERRUCA
2 205,808 1% RESPIRATORY DISTRESS SYNDROME
RETINOPATHY UNSPECIFIED
3 203,756 1% CHEST PAIN (UNSPECIFIC REASON)
DIABETES MELLITUS (DM)
DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION TYPE I -JUVENILE TYPE
GANGRENE
ISCHEMIC HEART DISEASE (IHD)
PALPITATIONS
PERIPHERAL VASCULAR DISEASE / ISCHEMIA
VARICOSE VEINS LEG
WOUND
4 201,981 1% RESPIRATORY DISTRESS SYNDROME
5 200,000 1% DIABETES WITH KETOACIDOSIS
User: Maged Hamdy 5 of 12 May 5, 2019 4:40:56 PM
Paid date from : 2018-11-1 to : 2019-4-30
Top 10 Claimant based on Paid Amount
Top 10 Claimant
Paid Amount % of Total
Major Conditions
6 186,660 1% DERMATITIS (& CONTACT) / ECZEMA
FRACTURE UNSPECIFIC BONE - CLOSED
OPEN FRACTURE OF SHAFT OF TIBIA ALONE
RENAL COLIC
THROMBOPHLEBITIS
7 177,445 1% ABSCESS / CELLULITIS
ACUTE VENOUS EMBOLISM AND THROMBOSIS OF SUBCLAVIAN VEINS
BREAST TUMOR - MALIGNANT -FEMALE
BRONCHITIS, ACUTE
CARBUNCLE / FURUNCLE
CHEMOTHERAPY-INDUCED NAUSEA AND VOMITING
CHEST PAIN (UNSPECIFIC REASON)
CONJUNCTIVITIS, ACUTE
GASTRITIS
GASTROENTERITIS / ENTERITIS OR COLITIS
HYPERTENSION
ISCHEMIC HEART DISEASE (IHD)
OSTEOPOROSIS
SORE THROAT / PHARYNGITIS, ACUTE
UNSPECIFIED GASTRITIS AND GASTRODUODENITIS WITHOUT MENTION OF HEMORRHAGE
UPPER RESPIRATORY INFECTION (URTI / URI)
VARICOSE VEINS LEG
VENOUS THROMBOSIS / DEEP VENOUS THROMBOSIS (DVT)
VERTIGO / DIZZINESS / GIDDINESS
WOUND
8 153,617 1% ABDOMINAL PAIN
BRONCHIAL ASTHMA
CHEST INFECTION
CHOLECYSTITIS
CHOLELITHIASIS / GALLBLADDER STONE
COLON / LARGE INTESTINE TUMOR - MALIGNANT
GASTRITIS
GASTROENTERITIS / ENTERITIS OR COLITIS
HYPERTENSION
INTERVERTEBRAL DISC
IRRITABLE COLON / IRRITABLE BOWEL SYNDROME (IBS)
OSTEOARTHRITIS
User: Maged Hamdy 6 of 12 May 5, 2019 4:40:56 PM
Paid date from : 2018-11-1 to : 2019-4-30
Top 10 Claimant based on Paid Amount
Top 10 Claimant
Paid Amount % of Total
Major Conditions
8 153,617 1% OTHER SPECIFIED AFTERCARE FOLLOWING SURGERY
OTHER SPRAIN OF FOOT
PAIN IN LIMBS / HAND PAIN / LEG PAIN
PERSONAL HISTORY OF COLONIC POLYPS
UNSPECIFIED GASTRITIS AND GASTRODUODENITIS WITHOUT MENTION OF HEMORRHAGE
VARICOSE VEINS LEG
WOUND
9 131,827 1% BRONCHIAL ASTHMA
BRONCHITIS, ACUTE
CHEST PAIN (UNSPECIFIC REASON)
COUGH
DIABETES MELLITUS (DM)
DIABETES WITH KETOACIDOSIS
DYSFUNCTIONAL UTERINE BLEEDING (DUB)
FEVER
PNEUMONIA / PNEUMONITIS
SHORTNESS OF BREATH (SOB) / DYSPNEA
10 122,324 1% ABDOMINAL PAIN
ALLERGY
ASTHMATIC BRONCHITIS
BRONCHIAL ASTHMA
BRONCHITIS, ACUTE
CHEST PAIN (UNSPECIFIC REASON)
DENTAL
DIABETES MELLITUS (DM)
FATTY LIVER
GASTROENTERITIS / ENTERITIS OR COLITIS
HYPERTENSION
IRRITABLE COLON / IRRITABLE BOWEL SYNDROME (IBS)
MALAISE / FATIGUE
NEUROPATHY UNSPECIFIC
OTITIS MEDIA
PELVIC PAIN / LOWER ABDOMINAL PAIN
PYLORIC STENOSIS
REFLUX ESOPHAGITIS
SMALL BOWEL / INTESTINE TUMOR - MALIGNANT
ULCERATIVE COLITIS
User: Maged Hamdy 7 of 12 May 5, 2019 4:40:56 PM
Paid date from : 2018-11-1 to : 2019-4-30
Top 10 Claimant based on Paid Amount
Top 10 Claimant
Paid Amount % of Total
Major Conditions
10 122,324 1% WOUND
Top 10 1,795,661 11%
Others 15,083,245 89%
Summary 16,878,906 100%
User: Maged Hamdy 8 of 12 May 5, 2019 4:40:56 PM
Paid date from : 2018-11-1 to : 2019-4-30
Top 10 Providers based on Paid Amount
Top 10 Providers Paid Amount Claim_Count % of Total
AS-SALAM INT'L HOSPITAL 2,901,301 699 18%
Al Nakheel Hospital 1,517,631 614 9%
EZABY PHARMACY 1,310,484 3,308 8%
CLEOPATRA HOSPITAL 906,163 311 6%
Dr. El Hakim Pharmacy 856,169 1,969 5%
SAUDI GERMAN HOSPITAL 723,832 268 5%
ANEES & RAMZY PHARMACY 709,070 1,623 4%
DR. KAMAL HUSSIEN PHARMACY 469,023 877 3%
ROUSHDY PHARMACIES 454,536 1,389 3%
NADA HOSPITAL 431,092 25 3%
Top 10 10,279,302 64%
User: Maged Hamdy 9 of 12 May 5, 2019 4:40:56 PM
Paid date from : 2018-11-1 to : 2019-4-30
001 AMERICAN EMBASSY
Top 10 Providers Paid Amount % of Total
AS-SALAM INT'L HOSPITAL 2,734,159 19%
Al Nakheel Hospital 1,321,400 9%
EZABY PHARMACY 1,283,662 9%
Dr. El Hakim Pharmacy 852,803 6%
CLEOPATRA HOSPITAL 774,533 5%
SAUDI GERMAN HOSPITAL 716,634 5%
ANEES & RAMZY PHARMACY 575,248 4%
DR. KAMAL HUSSIEN PHARMACY 465,241 3%
ROUSHDY PHARMACIES 428,634 3%
AL SALAM HOSPITAL 351,512 2%
Top 10 9,503,826 65%
Others 5,227,622 35%
001 AMERICAN EMBASSY 14,731,448 100%
001 AMERICAN EMBASSY USAID
Top 10 Providers Paid Amount % of Total
NADA HOSPITAL 408,685 29%
Al Nakheel Hospital 196,232 14%
AS-SALAM INT'L HOSPITAL 167,143 12%
ANEES & RAMZY PHARMACY 133,823 10%
CLEOPATRA HOSPITAL 131,629 9%
Alfa Lab 52,634 4%
ALFA SCAN 26,969 2%
EZABY PHARMACY 26,822 2%
ROUSHDY PHARMACIES 25,902 2%
AL SALAM HOSPITAL 23,210 2%
Top 10 1,193,048 85%
Others 207,753 15%
001 AMERICAN EMBASSY USAID 1,400,801 100%
User: Maged Hamdy 10 of 12 May 5, 2019 4:40:56 PM
Paid date from : 2018-11-1 to : 2019-4-30
CASH Claims Detail CASH Claims - Paid Amount Paid Amount
Country 001 AMERICAN EMBASSY 646,537
AMERICAN EMBASSY USAID 100,120
Sub total 746,657
Total 746,657
CASH Claims - Claim Count Claim_Count
Country 001 AMERICAN EMBASSY 1,257
AMERICAN EMBASSY USAID 231
Sub total 1,488
Total 1,488
PPO Claims Detail PPO Claims - Paid Amount Paid Amount
Country 001 AMERICAN EMBASSY 14,731,448
AMERICAN EMBASSY USAID 1,400,801
Sub total 16,132,249
Total 16,132,249
PPO Claims - Claim Count Claim_Count
Country 001 AMERICAN EMBASSY 36,720
AMERICAN EMBASSY USAID 1,763
Sub Total 38,483
Total 38,483
User: Maged Hamdy 11 of 12 May 5, 2019 4:40:56 PM
Paid date from : 2018-11-1 to : 2019-4-30
Claims by Insured Type Insured Op Medication Outpatient Inpatient Maternity Dental Optical Other Services Total % of Total
Employees 2,891,510 2,028,816 2,629,471 60,906 161,980 78,532 7,851,214 47%
Spouse 1,611,095 1,516,877 2,237,284 264,825 114,602 39,946 5,784,629 34%
Child 823,681 1,100,105 1,123,257 217 103,274 67,373 25,155 3,243,062 19%
Total 5,326,286 4,645,798 5,990,013 325,947 379,856 185,851 25,155 16,878,906 100%
Claims by Age Range Age Range Paid Amount Claim count
Male Female Total Female Male Total
Under 21 1,229,869 1,459,281 2,689,150 4,854 5,240 10,094
21-25 268,535 354,913 623,448 824 475 1,299
26-30 190,592 402,281 592,873 1,184 544 1,728
31-35 563,294 676,650 1,239,943 1,581 1,284 2,865
36-40 686,040 1,022,050 1,708,090 1,999 1,911 3,910
41-45 1,046,840 1,487,966 2,534,806 1,958 2,681 4,639
46-50 1,577,109 1,277,922 2,855,032 1,831 2,676 4,507
51-55 972,223 804,960 1,777,183 1,125 1,953 3,078
56-60 1,570,260 715,546 2,285,805 969 2,655 3,624
61-65 304,856 217,067 521,923 211 499 710
66-69 44,382 6,270 50,652 22 30 52
Total 8,454,000 8,424,905 16,878,906 16,558 19,948 36,506
Note: All amounts are in Policy Currency
User: Maged Hamdy 12 of 12 May 5, 2019 4:40:56 PM
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