5-Attachment H Historical Claims Information.pdf

Attachment H

Historical Claims Information

CITY OF LEANDER - Account #434679

Top Utilizers Over $15,000

Paid Period 06/01/2025 - 05/31/2026

Notice of Withheld Information – Texas Insurance Code (TIC) § 1215.003(d) provides that protected health information (PHI) may be withheld from this claims report if subject to privacy restrictions more stringent than HIPAA. This constitutes notice that following categories of claims information are withheld from this report: Records obtained in performance of UR per TIC §4201.552; Records regarding the diagnosis, evaluation, or treatment of a mental or emotional disorder, including alcoholism or drug addiction per Chap 611 of the TX Health & Safety Code; Records regarding AIDS and HIV test results per TX Health & Safety Code § 81.101 et seq.; and Genetic information, if any, per TIC § 546.102

DOB

Primary DX

Code

Primary DX

Description

Primary

Procedure Code Primary Procedure Code Description

Earliest Incurred

Date

Total

Payments

Case

Manageme nt Y/N

Med. Mgmt.

and Engagement

3/5/2002 O321XX0 Maternal care for breech presentation, not applicable or unspecified0449U

Carrier screening for severe inherited conditions

(eg, cystic fibrosis, spinal muscular atrophy, beta hemoglobinopathies (including sickle cell disease), alpha thalassemias) regardless of race or self-identified ancestry, genomic sequence analysis of 5 ge 5/1/2026 $15,562.52 N N

6/13/1979 M5126 Other intervertebral disc displacement, lumbar region63030

LAMINOTOMY (HEMILAMINECTOMY), WITH

DECOMPRESSION OF NERVE ROOT(S),

INCLUDING PARTIAL FACETECTOMY,

FORAMINOTOMY AND/OR EXCISION OF

HERNIATED INTERVERTEBRAL DISK; ONE

INTERSPACE, LUMBAR 2/12/2026 $16,827.53 N N

2/11/1992 O1414 Severe pre-eclampsia complicating childbirth59510

Routine obstetric care including antepartum care, cesarean delivery, and postpartum care 2/16/2026 $17,534.17 N

Member benefit termed on 01/01/2026

6/28/1965 J339 Nasal polyp, unspecified99214

Office or other outpatient visit for the evaluation and management of established patient, requires a medically appropriate history and/or examination and moderate level of medical decision making, 30-39 minutes of total time is spent on date of encounter 1/20/2026 $20,517.05 N N

CAS Page 1 of 4 Request #2430992 - 06/23/2026

Paid Period 06/01/2025 - 05/31/2026

Notice of Withheld Information – Texas Insurance Code (TIC) § 1215.003(d) provides that protected health information (PHI) may be withheld from this claims report if subject to privacy restrictions more stringent than HIPAA. This constitutes notice that following categories of claims information are withheld from this report: Records obtained in performance of UR per TIC §4201.552; Records regarding the diagnosis, evaluation, or treatment of a mental or emotional disorder, including alcoholism or drug addiction per Chap 611 of the TX Health & Safety Code; Records regarding AIDS and HIV test results per TX Health & Safety Code § 81.101 et seq.; and Genetic information, if any, per TIC § 546.102

DOB

Primary DX

Code

Primary DX

Description

Primary

Procedure Code Primary Procedure Code Description

Earliest Incurred

Date

Total

Payments

Case

Manageme nt Y/N

Med. Mgmt.

and Engagement

2/4/1961 Z0001 Encounter for general adult medical examination with abnormal findings99397

PERIODIC PREVENTIVE MEDICINE

REEVALUATION AND MANAGEMENT OF AN

INDIVIDUAL INCLUDING A COMPREHENSIVE

HISTORY, COMPREHENSIVE EXAMINATION,

COUNSELING/ANTICIPATORY

GUIDANCE/RISK FACTOR REDUCTION

INTERVENTIONS, AND THE ORDERING OF

APPR 2/24/2026 $20,944.00 N

Member benefit termed on 01/01/2026

1/3/1956 N401 Enlarged prostate with lower urinary tract symptoms98006

Synchronous audio-video visit for the evaluation and management of an established patient, moderate 3/13/2026 $21,042.33 N N

1/31/2000 A419 Sepsis, unspecified organism99285

Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making 5/14/2026 $21,271.68 N N

12/28/1994 S42022A Displaced fracture of shaft of left clavicle, initial encounter for closed fracture23515

OPEN TREATMENT OF CLAVICULAR

FRACTURE, WITH OR WITHOUT INTERNAL

OR EXTERNAL FIXATION 2/16/2026 $24,839.01 N N

11/2/2016 M0899 Juvenile arthritis, unspecified, multiple sites008070

COMPREHENSIVE ORTHODONTIC

TREATMENT OF THE TRANSITIONAL

DENTITION 4/21/2026 $27,530.82 N N

CAS Page 2 of 4 Request #2430992 - 06/23/2026

Paid Period 06/01/2025 - 05/31/2026

Notice of Withheld Information – Texas Insurance Code (TIC) § 1215.003(d) provides that protected health information (PHI) may be withheld from this claims report if subject to privacy restrictions more stringent than HIPAA. This constitutes notice that following categories of claims information are withheld from this report: Records obtained in performance of UR per TIC §4201.552; Records regarding the diagnosis, evaluation, or treatment of a mental or emotional disorder, including alcoholism or drug addiction per Chap 611 of the TX Health & Safety Code; Records regarding AIDS and HIV test results per TX Health & Safety Code § 81.101 et seq.; and Genetic information, if any, per TIC § 546.102

DOB

Primary DX

Code

Primary DX

Description

Primary

Procedure Code Primary Procedure Code Description

Earliest Incurred

Date

Total

Payments

Case

Manageme nt Y/N

Med. Mgmt.

and Engagement

9/24/2022 R6889 Other general symptoms and signs97153

Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with one patient, each

15 minutes 1/5/2026 $31,373.09 N N 11/26/1995 S83511A Sprain of anterior cruciate ligament of right knee, initial encounterC1713 ANCHOR/SCREW BN/BN,TIS/BN 1/7/2026 $33,790.03 N N

4/13/1979 M3500 Sicca syndrome, unspecified74230

Radiologic examination, swallowing function, with cineradiography/videoradiography, including scout neck radiograph(s) and delayed image(s), when performed, contrast (eg, barium) study 2/4/2026 $33,958.52 N N

5/15/1984 Z0000 Encounter for general adult medical examination without abnormal findings98972

Nonphysician qualified health care professional online digital assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes 3/20/2026 $37,957.92 N N

4/16/1969 M1712 Unilateral primary osteoarthritis, left knee20985

COMPUTER-ASSISTED SURGICAL

NAVIGATIONAL PROCEDURE FOR

MUSCULOSKELETAL PROCEDURES; IMAGE-

LESS 2/2/2026 $37,962.31 N N

2/23/1973 M461 Sacroiliitis, not elsewhere classified27279 placement of transarticular device(s) and/or intra-articular device(s) piercing the lateral or medial cortices of the ilium and the lateral cortex of the sacrum 2/16/2026 $40,393.20 N N

CAS Page 3 of 4 Request #2430992 - 06/23/2026

Paid Period 06/01/2025 - 05/31/2026

Notice of Withheld Information – Texas Insurance Code (TIC) § 1215.003(d) provides that protected health information (PHI) may be withheld from this claims report if subject to privacy restrictions more stringent than HIPAA. This constitutes notice that following categories of claims information are withheld from this report: Records obtained in performance of UR per TIC §4201.552; Records regarding the diagnosis, evaluation, or treatment of a mental or emotional disorder, including alcoholism or drug addiction per Chap 611 of the TX Health & Safety Code; Records regarding AIDS and HIV test results per TX Health & Safety Code § 81.101 et seq.; and Genetic information, if any, per TIC § 546.102

DOB

Primary DX

Code

Primary DX

Description

Primary

Procedure Code Primary Procedure Code Description

Earliest Incurred

Date

Total

Payments

Case

Manageme nt Y/N

Med. Mgmt.

and Engagement

5/10/1977 Z1231 Encounter for screening mammogram for malignant neoplasm of breast99396

PERIODIC PREVENTIVE MEDICINE

REEVALUATION AND MANAGEMENT OF AN

INDIVIDUAL INCLUDING A COMPREHENSIVE

HISTORY, COMPREHENSIVE EXAMINATION,

COUNSELING/ANTICIPATORY

GUIDANCE/RISK FACTOR REDUCTION

INTERVENTIONS, AND THE ORDERING OF

APPR 1/27/2026 $46,565.68 N N

3/24/2000 S86012A Strain of left Achilles tendon, initial encounterC1713 ANCHOR/SCREW BN/BN,TIS/BN 3/25/2026 $64,774.43 N N

12/12/2012 R6889 Other general symptoms and signsH0035 MH PARTIAL HOSP TX UNDER 24H 2/23/2026 $69,052.13 N N

2/16/1979 K5150 Left sided colitis without complicationsJ2327 Injection, risankizumab-rzaa, intravenous, 1 mg 1/19/2026 ######### N N

7/26/2010 Z5111 Encounter for antineoplastic chemotherapyQ5118

Injection, bevacizumab-bvzr, biosimilar, (Zirabev), 10 mg 3/25/2026 ######### N N

CAS Page 4 of 4 Request #2430992 - 06/23/2026

Paid Period 06/01/2025 - 05/31/2026

Notice of Withheld Information – Texas Insurance Code (TIC) § 1215.003(d) provides that protected health information (PHI) may be withheld from this claims report if subject to privacy restrictions more stringent than HIPAA. This constitutes notice that following categories of claims information are withheld from this report: Records obtained in performance of UR per TIC §4201.552; Records regarding the diagnosis, evaluation, or treatment of a mental or emotional disorder, including alcoholism or drug addiction per Chap 611 of the TX Health & Safety Code; Records regarding AIDS and HIV test results per TX Health & Safety Code § 81.101 et seq.; and Genetic information, if any, per TIC § 546.102

DOB

Primary DX

Code

Primary DX

Description Primary Procedure Code Primary Procedure Code Description Earliest Incurred Date Total Payments

Case

Manageme nt Y/N

03/05/2002 O321XX0 Maternal care for breech presentation, not applicable or unspecified0449U Carrier screening for severe inherited conditions (eg, cystic fibrosis, spinal muscular atrophy, beta hemoglobinopathies (including sickle cell disease), alpha thalassemias) regardless of race or self-identified ancestry, genomic sequence analysis of 5 ge05/01/2026 $15,562.52 N

06/13/1979 M5126 Other intervertebral disc displacement, lumbar region63030 LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISK; ONE INTERSPACE, LUMBAR02/12/2026 $16,827.53 N

02/11/1992 O1414 Severe pre-eclampsia complicating childbirth59510 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care 02/16/2026 $17,534.17 N

06/28/1965 J339 Nasal polyp, unspecified 99214 Office or other outpatient visit for the evaluation and management of established patient, requires a medically appropriate history and/or examination and moderate level of medical decision making, 30-39 minutes of total time is spent on date of encounter01/20/2026 $20,517.05 N

02/04/1961 Z0001 Encounter for general adult medical examination with abnormal findings99397 PERIODIC PREVENTIVE MEDICINE REEVALUATION AND MANAGEMENT OF AN INDIVIDUAL INCLUDING A COMPREHENSIVE HISTORY, COMPREHENSIVE EXAMINATION, COUNSELING/ANTICIPATORY GUIDANCE/RISK FACTOR REDUCTION INTERVENTIONS, AND THE ORDERING OF APPR02/24/2026 $20,944.00 N

01/03/1956 N401 Enlarged prostate with lower urinary tract symptoms98006 Synchronous audio-video visit for the evaluation and management of an established patient, moderate 03/13/2026 $21,042.33 N

01/31/2000 A419 Sepsis, unspecified organism99285 Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making05/14/2026 $21,271.68 N

12/28/1994 S42022A Displaced fracture of shaft of left clavicle, initial encounter for closed fracture23515 OPEN TREATMENT OF CLAVICULAR FRACTURE, WITH OR WITHOUT INTERNAL OR EXTERNAL FIXATION02/16/2026 $24,839.01 N

11/02/2016 M0899 Juvenile arthritis, unspecified, multiple sites008070 COMPREHENSIVE ORTHODONTIC TREATMENT OF THE TRANSITIONAL DENTITION 04/21/2026 $27,530.82 N

09/24/2022 R6889 Other general symptoms and signs97153 Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with one patient, each 15 minutes01/05/2026 $31,373.09 N

11/26/1995 S83511A Sprain of anterior cruciate ligament of right knee, initial encounterC1713 ANCHOR/SCREW BN/BN,TIS/BN 01/07/2026 $33,790.03 N

04/13/1979 M3500 Sicca syndrome, unspecified74230 Radiologic examination, swallowing function, with cineradiography/videoradiography, including scout neck radiograph(s) and delayed image(s), when performed, contrast (eg, barium) study02/04/2026 $33,958.52 N

05/15/1984 Z0000 Encounter for general adult medical examination without abnormal findings98972 Nonphysician qualified health care professional online digital assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes03/20/2026 $37,957.92 N

04/16/1969 M1712 Unilateral primary osteoarthritis, left knee20985 COMPUTER-ASSISTED SURGICAL NAVIGATIONAL PROCEDURE FOR MUSCULOSKELETAL PROCEDURES; IMAGE-LESS02/02/2026 $37,962.31 N

02/23/1973 M461 Sacroiliitis, not elsewhere classified27279 placement of transarticular device(s) and/or intra-articular device(s) piercing the lateral or medial cortices of the ilium and the lateral cortex of the sacrum02/16/2026 $40,393.20 N

05/10/1977 Z1231 Encounter for screening mammogram for malignant neoplasm of breast99396 PERIODIC PREVENTIVE MEDICINE REEVALUATION AND MANAGEMENT OF AN INDIVIDUAL INCLUDING A COMPREHENSIVE HISTORY, COMPREHENSIVE EXAMINATION, COUNSELING/ANTICIPATORY GUIDANCE/RISK FACTOR REDUCTION INTERVENTIONS, AND THE ORDERING OF APPR01/27/2026 $46,565.68 N

03/24/2000 S86012A Strain of left Achilles tendon, initial encounterC1713 ANCHOR/SCREW BN/BN,TIS/BN 03/25/2026 $64,774.43 N

12/12/2012 R6889 Other general symptoms and signsH0035 MH PARTIAL HOSP TX UNDER 24H 02/23/2026 $69,052.13 N

02/16/1979 K5150 Left sided colitis without complicationsJ2327 Injection, risankizumab-rzaa, intravenous, 1 mg 01/19/2026 $127,797.87 N

07/26/2010 Z5111 Encounter for antineoplastic chemotherapyQ5118 Injection, bevacizumab-bvzr, biosimilar, (Zirabev), 10 mg 03/25/2026 $178,295.25 N

CAS Page 1 of 1 Request #2430992 - 06/23/2026

CITY OF LEANDER - Account #315854

Paid Period 07/01/2023 - 06/30/2024

Notice of Withheld Information – Texas Insurance Code (TIC) § 1215.003(d) provides that protected health information (PHI) may be withheld from this claims report if subject to privacy restrictions more stringent than HIPAA. This constitutes notice that following categories of claims information are withheld from this report: Records obtained in performance of UR per TIC §4201.552; Records regarding the diagnosis, evaluation, or treatment of a mental or emotional disorder, including alcoholism or drug addiction per Chap 611 of the TX Health & Safety Code; Records regarding AIDS and HIV test results per TX Health & Safety Code § 81.101 et seq.; and Genetic information, if any, per TIC § 546.102

DOB

Primary DX

Code

Primary DX

Description

Primary Procedure

Code Primary Procedure Code Description Earliest Incurred Date Total Payments

Case

Manageme

03/29/1996 O368130 Decreased fetal movements, third trimester, not applicable or unspecified59510 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care 02/12/2024 $15,196.06 N

05/29/2001 R6889 Other general symptoms and signs99199 UNLISTED SPECIAL SERVICE OR REPORT 08/09/2023 $15,322.50 N

04/13/1979 R6889 Other general symptoms and signs99214 Office or other outpatient visit for the evaluation and management of established patient, requires a medically appropriate history and/or examination and moderate level of medical decision making, 30-39 minutes of total time is spent on date of encounter10/16/2023 $15,777.72 N

11/04/1972 Z0000 Encounter for general adult medical examination without abnormal findings77067 Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed01/23/2024 $16,019.12 N

03/22/1958 K8012 Calculus of gallbladder with acute and chronic cholecystitis without obstruction47562 LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY 04/08/2024 $16,060.00 N

07/31/1961 S42142A Displaced fracture of glenoid cavity of scapula, left shoulder, initial encounter for closed fracture99285 Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making07/30/2023 $16,697.52 N

02/12/2024 Z3801 Single liveborn infant, delivered by cesarean99285 Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making02/12/2024 $17,674.27 N

10/04/1971 M19072 Primary osteoarthritis, left ankle and footC1713 ANCHOR/SCREW BN/BN,TIS/BN 04/09/2024 $18,475.16 N

01/12/1970 I10 Essential (primary) hypertension99214 Office or other outpatient visit for the evaluation and management of established patient, requires a medically appropriate history and/or examination and moderate level of medical decision making, 30-39 minutes of total time is spent on date of encounter09/19/2023 $18,675.07 N

06/14/1959 Z1211 Encounter for screening for malignant neoplasm of colon45380 COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH BIOPSY, SINGLE OR MULTIPLE 06/29/2023 $19,528.17 N

05/04/2001 S83512A Sprain of anterior cruciate ligament of left knee, initial encounter29888 ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUGMENTATION OR RECONSTRUCTION 12/20/2023 $20,910.32 N

05/07/1974 E213 Hyperparathyroidism, unspecified60500 PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S); 03/13/2024 $22,087.47 N

08/26/1979 C561 Malignant neoplasm of right ovary58573 LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S)01/29/2024 $22,121.90 N

02/01/1973 Z1211 Encounter for screening for malignant neoplasm of colon45380 COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH BIOPSY, SINGLE OR MULTIPLE 09/25/2023 $22,218.69 N

09/15/1972 N390 Urinary tract infection, site not specified87798 NOT OTHERWISE SPECIFIED, AMPLIFIED PROBE TECHNIQUE 09/15/2023 $23,978.79 N

03/03/2007 R6889 Other general symptoms and signsS0201 PARTIAL HOSPITALIZATION SERVICES, LESS THAN 24 HOURS, PER DIEM 03/06/2023 $24,814.88 N

08/29/1994 R6889 Other general symptoms and signs58661 LAPAROSCOPY, SURGICAL; WITH REMOVAL OF ADNEXAL STRICTURES 05/15/2024 $25,433.80 N

11/24/2000 K2211 Ulcer of esophagus with bleeding99285 Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making12/12/2023 $25,842.51 N

02/16/1987 N611 Abscess of the breast and nipple00400 Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; not otherwise specified09/22/2023 $26,540.46 N

08/01/1990 E042 Nontoxic multinodular goiter60271 THYROIDECTOMY, INCLUDING SUBSTERNAL THYROID GLAND; CERVICAL APPROACH 01/08/2024 $26,845.09 N

12/17/1974 K5000 Crohn's disease of small intestine without complicationsJ1745 INJECTION INFLIXIMAB, 10 MG 07/20/2023 $27,663.18 N

06/23/1983 S0990XA Unspecified injury of head, initial encounter92507 TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING DISORDER (INCLUDES AURAL REHABILITATION); INDIVIDUAL03/02/2024 $29,539.65 N

11/04/1985 R6889 Other general symptoms and signsH2036 A/D TX PROGRAM, PER DIEM 07/20/2022 $38,652.17 N

03/11/1968 C61 Malignant neoplasm of prostate55866 LAPAROSCOPY, SURGICAL PROSTATECOMY, RETROPUBIC RADICAL, INCLUDING NERVE SPARING 07/08/2023 $39,855.86 N

06/28/1965 M25551 Pain in right hip 99244 Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selectio10/11/2023 $43,338.14 N

02/23/1973 R6889 Other general symptoms and signs99199 UNLISTED SPECIAL SERVICE OR REPORT 07/13/2023 $44,057.08 N

07/25/1964 M1711 Unilateral primary osteoarthritis, right kneeC1776 JOINT DEVICE (IMPLANTABLE) 11/17/2023 $59,787.99 N

05/31/1969 G894 Chronic pain syndromeC1772 INFUSION PUMP, PROGRAMMABLE 03/05/2024 $60,855.08 N

07/29/1970 G894 Chronic pain syndromeL8688 IMPLANTABLE NEUROSTIMULATOR PULSE GENERATOR, DUAL ARRAY, NON-RECHARGEABLE,INCLUDES EXTENSIONINCLUDES EXTENSION01/18/2024 $64,301.91 N

09/04/1979 I480 Paroxysmal atrial fibrillation93656 Additions to code descriptor to indicate that the service includes 3-dimensional mapping and echocardiography 07/07/2023 $71,805.49 N

04/16/1984 S83512A Sprain of anterior cruciate ligament of left knee, initial encounter29888 ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUGMENTATION OR RECONSTRUCTION 11/14/2023 $72,201.54 N

09/03/2023 Z3800 Single liveborn infant, delivered vaginally99468 1ST INPATIENT CRITICAL CARE PR DAY AGE 28 DAYS/< 09/03/2023 $79,409.32 N

11/05/1963 A419 Sepsis, unspecified organism00210 ANESTHESIA FOR INTRACRANIAL PROCEDURES; NOT OTHERWISE SPECIFIED 02/19/2024 $86,729.88 N

11/02/2016 J0301 Acute recurrent streptococcal tonsillitis42820 TONSILLECTOMY AND ADENOIDECTOMY; UNDER AGE 12 01/30/2024 $90,417.32 N

07/21/1980 R6889 Other general symptoms and signs99214 Office or other outpatient visit for the evaluation and management of established patient, requires a medically appropriate history and/or examination and moderate level of medical decision making, 30-39 minutes of total time is spent on date of encounter08/10/2023 $94,264.01 N

05/15/1984 G35 Multiple sclerosis 99214 Office or other outpatient visit for the evaluation and management of established patient, requires a medically appropriate history and/or examination and moderate level of medical decision making, 30-39 minutes of total time is spent on date of encounter07/25/2023 $103,207.66 N

02/04/1961 M5116 Intervertebral disc disorders with radiculopathy, lumbar region95941 Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby) or for monitoring of more than one case while in the operating room, per hour (List separately in addition to code for primary procedure)06/21/2023 $142,852.73 N

04/26/2010 R6889 Other general symptoms and signsS0201 PARTIAL HOSPITALIZATION SERVICES, LESS THAN 24 HOURS, PER DIEM 10/16/2023 $158,353.61 N

05/20/1986 Z510 Encounter for antineoplastic radiation therapy77386 Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; complex 03/12/2024 $210,830.26 N

04/04/1972 I610 Nontraumatic intracerebral hemorrhage in hemisphere, subcortical99291 CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE UNSTABLE CRITICALLY ILL OR UNSTABLE CRITICALLY INJURED PATIENT, REQUIRING THE CONSTANT ATTENDANCE OF THE PHYSICIAN; FIRST HOUR08/13/2023 $278,212.94 N

02/16/1979 K6289 Other specified diseases of anus and rectum45380 COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH BIOPSY, SINGLE OR MULTIPLE 02/27/2024 $337,502.02 N

CAS Page 1 of 1 Request #1913413 - 07/16/2024

Legislative Report - Tier 1 Totals by Month

Paid Period 01/01/2026 - 05/31/2026

Incurred Period 01/01/2026 - 05/31/2026

Month

Account

Number

Employee Only

Contract Count

Employee +

Spouse

Contract Count

Employee +

Child(ren)

Contract Count

Employee +

Family Contract

Count

Employee Only

Member Count

Employee +

Spouse

Member Count

Employee +

Child(ren)

Member Count

Employee +

Family Member

Count Billed Premium Total Payments

May 2026 434679 262 29 86 69 262 58 243 278 $416,138.27 $399,564.59

April 2026 434679 266 28 83 67 266 56 236 271 $410,336.25 $406,172.53

March 2026 434679 265 27 82 65 265 54 233 264 $404,004.38 $436,945.92

February 2026 434679 262 28 81 64 262 56 229 259 $401,209.83 $273,271.74

January 2026 434679 260 31 83 63 260 62 233 256 $404,859.36 $143,358.54

CAS CAS Reporting Request #2431000 - 06/23/2026

City of Leander Run Out Claims

Run Date: 4/10/2025

Metrics:

Rows: (Loss Ratio Month)

Columns: (Metrics)

Loss Ratio Month: Last 12 Months

[Mar 2024 - Feb

Database: (CITY OF

LEANDER: ALL)

Loss Ratio Month Medical

Subscribers

Months

Medical

Members

Months

Loss Ratio Medical and

Pharmacy Premium

Loss Ratio Medical

Paid Claims

Loss Ratio Pharmacy

Paid Claims

Loss Ratio VBC

Payments

Loss Ratio

Medical and

Pharmacy Total

Paid

Medical and

Pharmacy Loss

Ratio

Mar 2024 397 764 $401,678.28 $239,255.39 $142,905.73 $912.39 $383,073.51 95.4%

Apr 2024 392 754 $398,213.28 $324,504.30 $82,471.97 $957.01 $407,933.28 102.4%

May 2024 394 760 $401,322.57 $231,809.82 $117,624.96 $968.20 $350,402.98 87.3%

Jun 2024 401 771 $408,013.75 $133,828.80 $67,630.00 $985.11 $202,443.91 49.6%

Jul 2024 402 755 $402,443.40 $290,677.62 $121,409.80 $945.48 $413,032.90 102.6%

Aug 2024 404 758 $403,880.63 $259,851.53 $107,841.11 $914.40 $368,607.04 91.3%

Sep 2024 406 758 $405,506.97 $397,610.45 $89,277.46 $925.34 $487,813.25 120.3%

Oct 2024 411 768 $410,822.46 $236,197.48 $130,185.16 $1,026.82 $367,409.46 89.4%

Nov 2024 410 765 $409,271.03 $374,191.88 $128,492.70 $1,226.58 $503,911.16 123.1%

Dec 2024 410 761 $406,979.21 $318,226.74 $82,404.70 $1,227.39 $401,858.83 98.7%

Jan 2025 $164,375.74 $24,052.85 $7.27 $188,435.86

Feb 2025 $43,860.60 $7.10 $43,867.70

Total: Selected Filter(s) 4,027 7,614 $4,048,131.58 $3,014,390.35 $1,094,296.44 $10,103.09 $4,118,789.88 101.7%

(Medical Subscribers Months, Medical Members Months, Loss

Ratio Medical and Pharmacy

Premium, Loss Ratio Medical Paid

Claims, Loss Ratio Pharmacy

Paid Claims, Loss Ratio VBC

2025-04-10 City of Leander Run Out Claims.pdf