Appendix%207.8%20Claims%20and%20Utilization%20History.xlsx

XLSX spreadsheet 21 KB Posted Sep 15, 2026

Attached to: Third Party Administrator Services for the State's Public Sector Health Plans
Solicitation number: RFP 31786-00190
Issued by: Davidson County, Tennessee

About this file

Written by GovTribe AI · Sep 16, 2026

This file is a Claims and Utilization History appendix for Third Party Administrator (TPA) Services supporting Tennessee's public sector health plans, encompassing State/Higher Education, Local Education, and Local Government employee populations. The document provides comprehensive historical claims data and utilization metrics across three plan periods: January 2024 through December 2024, January 2025 through December 2025, and January 2026 through March 2026. The data encompasses medical claims costs, per-member-per-year (PMPY) metrics, acute hospital admissions, emergency room visits, outpatient office visits, and length-of-stay information segmented by the three covered populations.

The file demonstrates significant claims volume across all three sectors, with the State/Higher Education plan representing the largest population at approximately 144,000-147,000 average members, followed by Local Education at 120,000-123,000 members and Local Government at 26,000-29,000 members. Total net paid medical claims for the full-year 2024 period exceeded $1.3 billion across all three plans, with per-member annual costs ranging from approximately $4,085 to $5,499 PMPY. Key utilization metrics show relatively consistent patterns across plan periods, including acute admission rates of 43-57 per 1,000 members, average length of stay between 4.7-5.6 days, and office visit utilization between 8.2-9.4 visits per patient. The appendix includes detailed definitions of all metrics and methodologies used in calculating claims costs and utilization statistics, enabling prospective bidders to understand the historical baseline for financial projections and service level expectations.

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Claims Costs

Appendix 7.8
Historical Claims Costs
		State / Higher Education	Local Education	Local Government
Time Period Incurred Plan Year
Jan 2024 - Dec 2024	Net Pay Med	$718,467,253.68	$492,334,512.92	$146,280,737.61
	Net Pay PMPY Med	$4,963.62	$4,085.23	$5,499.07
	Net Pay PMPY OP Med	$3,598.68	$3,084.88	$3,611.40
	Net Pay PEPY Med	$10,523.93	$8,355.64	$8,497.49
	Net Pay PEPY OP Med	$7,629.96	$6,309.60	$5,580.54
	Members Avg Med	144,746.5	120,515.8	26,601.0
	Employees Avg Med	68,269.8	58,922.4	17,214.6
	Admits Acute	7,189	5,188	1,505
	Admits Per 1000 Acute	49.67	43.05	56.58
	Patients Admit Acute	5,524	4,175	1,179
	Days LOS Admit Acute	5.47	4.69	5.42
	Visits ER Admit	3,930	2,324	905
	Visits Office Med	1,311,803	1,021,125	218,385
	Visits Per Pat Office Med	9.33	8.59	8.16
Jan 2025 - Dec 2025	Net Pay Med	$744,734,096.00	$526,451,310.98	$142,404,229.61
	Net Pay PMPY Med	$5,075.27	$4,296.14	$5,398.53
	Net Pay PMPY OP Med	$3,731.35	$3,312.06	$3,845.23
	Net Pay PEPY Med	$10,779.25	$8,749.81	$8,415.75
	Net Pay PEPY OP Med	$7,924.94	$6,745.56	$5,994.31
	Members Avg Med	146,737.9	122,540.5	26,378.3
	Employees Avg Med	69,089.6	60,167.2	16,921.2
	Admits Acute	7,118	5,275	1,432
	Admits Per 1000 Acute	48.51	43.05	54.29
	Patients Admit Acute	5,551	4,399	1,146
	Days LOS Admit Acute	5.52	4.46	4.95
	Visits ER Admit	3,850	2,499	843
	Visits Office Med	1,333,610	1,041,147	216,122
	Visits Per Pat Office Med	9.40	8.70	8.21
Jan 2026 - Mar 2026	Net Pay Med	$167,173,825.06	$120,943,961.37	$34,247,983.77
	Net Pay PMPY Med	$4,526.09	$3,917.53	$4,667.42
	Net Pay PMPY OP Med	$3,336.33	$2,927.89	$3,439.44
	Net Pay PEPY Med	$9,619.02	$7,952.52	$7,291.07
	Net Pay PEPY OP Med	$7,090.49	$5,943.58	$5,372.82
	Members Avg Med	147,742.3	123,490.0	29,350.7
	Employees Avg Med	69,518.0	60,833.0	18,789.0
	Admits Acute	1,694	1,278	359
	Admits Per 1000 Acute	45.86	41.40	48.93
	Patients Admit Acute	1,485	1,109	304
	Days LOS Admit Acute	5.59	4.85	4.69
	Visits ER Admit	871	612	208
	Visits Office Med	325,467	255,123	58,005
	Visits Per Pat Office Med	3.32	3.07	2.98

Claims Utilization

Appendix 7.8
Historical Claims Utilization
		State / Higher Education	Local Education	Local Government
Time Period Incurred Plan Year
Jan 2024 - Dec 2024	Employees Avg Med	68,269.8	58,922.4	17,214.6
	Members Avg Med	144,746.5	120,515.8	26,601.0
	Patients Med	140,533	118,886	26,767
	Visits OP Phys	919,932	697,144	161,142
	Visits OP Prof	2,090,620	1,494,989	346,924
	Visits Per 1000 OP Phys	6,355.47	5,784.67	6,057.74
	Visits Per 1000 OP Prof Med	12,767.71	11,768.72	12,204.17
	Patients Admit	5,524	4,175	1,179
	Days Admit	39,346	24,323	8,161
	Days LOS Admit Acute	5.47	4.69	5.42
	Days Per 1000 Adm Acute	271.83	201.82	306.79
Jan 2025 - Dec 2025	Employees Avg Med	69,089.6	60,167.2	16,921.2
	Members Avg Med	146,737.9	122,540.5	26,378.3
	Patients Med	141,828	119,670	26,321
	Visits OP Phys	907,177	687,181	154,012
	Visits OP Prof	2,168,025	1,555,675	348,070
	Visits Per 1000 OP Phys	6,182.29	5,607.79	5,838.58
	Visits Per 1000 OP Prof Med	13,017.90	12,024.93	12,348.58
	Patients Admit	5,551	4,399	1,146
	Days Admit	39,277	23,518	7,088
	Days LOS Admit Acute	5.52	4.46	4.95
	Days Per 1000 Adm Acute	267.67	191.92	268.71
Jan 2026 - Mar 2026	Employees Avg Med	69,518.0	60,833.0	18,789.0
	Members Avg Med	147,742.3	123,490.0	29,350.7
	Patients Med	98,112	83,031	19,448
	Visits OP Phys	215,109	165,432	40,864
	Visits OP Prof	535,949	386,070	94,734
	Visits Per 1000 OP Phys	5,823.90	5,358.56	5,569.07
	Visits Per 1000 OP Prof Med	12,686.93	11,810.61	12,041.16
	Patients Admit	1,485	1,109	304
	Days Admit	9,474	6,192	1,683
	Days LOS Admit Acute	5.59	4.85	4.69
	Days Per 1000 Adm Acute	256.50	200.57	229.36

Definitions Definitions

Acute Admissions	Identification	Acute Admissions identifies admissions that took place in an acute inpatient setting. Acute inpatient settings include inpatient hospitals, birthing centers, inpatient psychiatric facilities, and residential substance abuse treatment facilities.
Admissions	Count	Admissions is the count of distinct of volumetric admit ID.
Admissions	Identification	Admissions identifies all admissions as well as any facility or professional claims included in an admission.
Admits	Volumetric	Admits is the number of acute and non-acute admissions.
Admits Acute	Constrained by Acute Admissions	Admits Acute is the number of acute admissions.
Admits Per 1000 Acute	(Admits Acute/(Member Months Med/1000))*12	Admits Per 1000 Acute is the average number of acute admissions per 1000 members with medical coverage per year.
Allow Amt PMPM	Allowed Amount/Member Months Eligibility	Allow Amt PMPM is the average amount of submitted charges eligible for payment for all claims, per member with any coverage type per month. It is the amount eligible after applying pricing guidelines, but before deducting third party, copayment, coinsurance, or deductible amounts.
Allow Amt PMPY	Allow Amt PMPM*12	Allow Amt PMPY is the average amount of submitted charges eligible for payment for all claims, per member per year. It is the amount eligible after applying pricing guidelines, but before deducting third party, copayment, coinsurance, or deductible amounts.
Days Admit	Volumetric	Days Admit is the number of days from admissions. The number of days is assigned during Admission Build. It is based on the days that were reported on those facility claims containing room and board services that are included in the admission.
Days Admit Acute	Constrained by Acute Admissions	Days Admit Acute is the number of days from acute admissions. The number of days is assigned during Admission Build. It is based on the days that were reported on those facility claims containing room and board services that are included in the admission.
Days LOS Admit Acute	Days Admit Acute/Admits Acute	Days LOS Admit Acute is the average length of stay for acute admissions.
Days Per 1000 Adm Acute	(Days Admit Acute/(Member Months Med/1000))*12	Days Per 1000 Adm Acute is the average number of days from acute admissions per 1000 members with medical coverage per year.
Eligibility Any	Identification	Eligibility Any identifies members with medical coverage, drug coverage, MHSA coverage, dental coverage, vision coverage, or hearing coverage.
Emergency Room Services	Identification	Emergency Room Services identifies all services provided in an emergency room (ER) setting or involving the activation of an emergency trauma team. It is based on Service Categories, which identifies ER services from both facility and professional claims, using place of service codes, revenue codes, and procedure codes. All services from an ER claim are included in this subset as long as they are stored under the same Claim ID.
Employee Months	Volumetric	Employee Months is the sum of employees by month with any coverage type. Each employee is counted once for each month that they are eligible. Employees can include active employees, retirees, surviving spouses, COBRA-eligible individuals, and employees on long term disability.
Employee Months Med	Constrained by Medical Eligibility	Employee Months Med is the sum of employees by month with medical coverage. Each employee is counted once for each month that they are eligible.
Employees Avg Med	Employee Months Med/Months Med	Employees Avg Med is the average number of employees per month with medical coverage. Each employee is counted once for each month of their eligibility, then the total is averaged across the total number of months of eligibility. Employees can include active employees, retirees, surviving spouses, COBRA-eligible individuals, and employees on long term disability.
Inpatient Acute	Identification	Inpatient Acute identifies claims for services provided under medical coverage in an acute inpatient setting. Acute inpatient settings include inpatient hospitals, birthing centers, inpatient psychiatric facilities, and residential substance abuse treatment facilities.
Medical Eligibility	Identification	Medical Eligibility identifies members with medical coverage.
Member Months	Volumetric	Member Months is the sum of members by month with any coverage type. Each member is counted once for each month of eligibility.
Member Months Med	Constrained by Medical Eligibility	Member Months Med is the sum of members by month with medical coverage. Each member is counted once for each month of eligibility.
Members Avg Med	Member Months Med/Months Med	Members Avg Med is the average number of members per month with medical coverage. Each member is counted once for each month they are eligible, then this count is divided by the overall number of months of eligibility.
Months	Count Distinct of Volumetric	Months is the number of months for which eligible members exist with any coverage type.
Months Med	Constrained by Medical Eligibility	Months Med is the number of months for which eligible members exist with medical coverage.
Net Pay Fac	Volumetric	Net Pay Fac is the net amount paid for facility services. It represents the amount after all pricing guidelines have been applied, and all third party, copayment, coinsurance, and deductible amounts have been subtracted.
Net Pay Fac Med	Identification	Net Pay Fac Med is the net amount paid for facility services provided under medical coverage. It represents the amount after all pricing guidelines have been applied, and all third party, copayment, coinsurance, and deductible amounts have been subtracted.
Net Pay Med	Identification	Net Pay Med is the net amount paid for facility and professional services provided under medical coverage. It represents the amount after all pricing guidelines have been applied, and all third party, copayment, coinsurance, and deductible amounts have been subtracted.
Net Pay OP Fac Med	Identification	Net Pay OP Fac Med is the net amount paid for outpatient facility services provided under medical coverage. It represents the amount after all pricing guidelines have been applied, and all third party, copayment, coinsurance, and deductible amounts have been subtracted.
Net Pay OP Med	Identification	Net Pay OP Med is the net amount paid for outpatient facility and professional services provided under medical coverage. It represents the amount after all pricing guidelines have been applied, and all third party, copayment, coinsurance, and deductible amounts have been subtracted.
Net Pay OP Prof Med	Identification	Net Pay OP Prof Med is the net amount paid for outpatient professional services provided under medical coverage. It represents the amount after all pricing guidelines have been applied, and all third party, copayment, coinsurance, and deductible amounts have been subtracted.
Net Pay PEPM Med	Net Pay Med/ Employee Months Med	Net Pay PEPM Med is the average net amount paid for services provided under medical coverage, per employee with medical coverage per month. It represents the amount after all pricing guidelines have been applied, and all third party, copayment, coinsurance, and deductible amounts have been subtracted.
Net Pay PEPM OP Med	Net Pay OP Med/ Employee Months Med	Net Pay PEPM OP Med is the average net amount paid for outpatient services provided under medical coverage, per employee with medical coverage per month. It represents the amount after all pricing guidelines have been applied, and all third party, copayment, coinsurance, and deductible amounts have been subtracted.
Net Pay PEPY Med	Net Pay PEPM Med*12	Net Pay PEPY Med is the average net amount paid for services provided under medical coverage, per employee with medical coverage per year. It represents the amount after all pricing guidelines have been applied, and all third party, copayment, coinsurance, and deductible amounts have been subtracted.
Net Pay PEPY OP Med	Net Pay PEPM OP Med*12	Net Pay PEPY OP Med is the average net amount paid for outpatient services provided under medical coverage, per employee with medical coverage per year. It represents the amount after all pricing guidelines have been applied, and all third party, copayment, coinsurance, and deductible amounts have been subtracted.
Net Pay PMPM Med	Net Pay Med/ Member Months Med	Net Pay PMPM Med is the average net amount paid for services provided under medical coverage, per member with medical coverage per month. It represents the amount after all pricing guidelines have been applied, and all third party, copayment, coinsurance, and deductible amounts have been subtracted.
Net Pay PMPM OP Med	Net Pay OP Med/ Member Months Med	Net Pay PMPM OP Med is the average net amount paid for outpatient services provided under medical coverage, per member with medical coverage per month. It represents the amount after all pricing guidelines have been applied, and all third party, copayment, coinsurance, and deductible amounts have been subtracted.
Net Pay PMPY Med	Net Pay PMPM Med*12	Net Pay PMPY Med is the average net amount paid for services provided under medical coverage, per member with medical coverage per year. It represents the amount after all pricing guidelines have been applied, and all third party, copayment, coinsurance, and deductible amounts have been subtracted.
Net Pay Prof	Volumetric	Net Pay Prof is the net amount paid for professional services. It represents the amount after all pricing guidelines have been applied, and all third party, copayment, coinsurance, and deductible amounts have been subtracted.
Net Pay Prof Med	Identification	Net Pay Prof Med is the net amount paid for professional services provided under medical coverage. It represents the amount after all pricing guidelines have been applied, and all third party, copayment, coinsurance, and deductible amounts have been subtracted.
Net Pay Rx	Volumetric	Net Pay Rx is the net amount paid for prescriptions filled. It represents the amount after all pricing guidelines have been applied, and all third party, copayment, coinsurance, and deductible amounts have been subtracted.
Outpatient Medical	Identification	Outpatient Medical identifies the medical claims for services provided in any non-inpatient setting. Outpatient settings include but are not limited to provider offices, patient homes, hospital-based outpatient clinics or facilities, emergency rooms, ambulatory surgical centers, military treatment facilities, ambulances (land, air, or water), psychiatric outpatient clinics or facilities, community mental health centers, mass immunization centers, comprehensive outpatient rehabilitation facilities, end-stage renal disease facilities, state or local public health clinics, rural health clinics, or independent laboratories.
Patients	Volumetric / Count	Patients is the unique count of members who received facility, professional, or pharmacy services.
Patients Admit	Volumetric / Count	Patients Admit is the unique count of members who were admitted to an inpatient acute or non-acute facility. Patients are included in this count if they received facility or professional services included in an admission.
Patients IP Acute	Constrained by Inpatient Acute	Patients IP Acute is the unique count of members who received inpatient acute facility or professional services provided under medical coverage.
Patients Med	Constrained by Medical Claims	Patients Med is the unique count of members who received facility or professional services provided under medical coverage.
Svcs Fac	Identification	Svcs Fac is the sum of the Service Count field for facility services.
Svcs Fac Med	Identification	Svcs Fac Med is the sum of the Service Count field for facility services provided under medical coverage.
Svcs IP Acute	Identification	Svcs IP Acute is the sum of the Service Count field for inpatient acute facility and professional services provided under medical coverage.
Svcs IP Acute Fac	Identification	Svcs IP Acute Fac is the sum of the Service Count field for inpatient acute facility services provided under medical coverage.
Svcs IP Acute Prof	Identification	Svcs IP Acute Prof is the sum of the Service Count field for inpatient acute professional services provided under medical coverage.
Svcs Med	Identification	Svcs Med is the sum of the Service Count field for facility and professional services provided under medical coverage.
Svcs Prof	Identification	Svcs Prof is the sum of the Service Count field for professional services.
Svcs Prof Med	Identification	Svcs Prof Med is the sum of the Service Count field for professional services provided under medical coverage.
Visits ER	Constrained by Emergency Room Services	Visits ER is the number of emergency room facility visits provided under medical coverage. The number of visits is based on the count of unique patient and service date combinations. This includes both ER visits that resulted in an admission and those that did not.
Visits ER Admit	Constrained by Admissions	Visits ER Admit is the number of emergency room facility visits included in admissions provided under medical coverage. The number of visits is based on the count of unique patient and service date combinations.
Visits Office Med	Constrained by Office Setting Medical	Visits Office Med is the number of professional visits provided in an office setting under medical coverage.
Visits OP Phys	Constrained by Outpatient Medical Physician Providers	Visits OP Phys is the number of outpatient professional visits provided under medical coverage that were performed by a physician.
Visits OP Prof	Constrained by Outpatient	Visits OP Prof is the number of outpatient professional visits.
Visits OP Prof Med	Constrained by Outpatient Medical	Visits OP Prof Med is the number of outpatient professional visits provided under medical coverage.
Visits Patient	Count	Visits Patient is the count of unique patient and service date combinations across all claims. This method for counting visits should be used when multiple providers could be involved in a single visit but the visit should only be counted once. For example, in preventive screening visits such as mammograms, there could be a facility provider claim as well as a professional provider claim. This method allows for these visits to be counted only once across all claims for the same patient on the same day.
Visits Patient Fac	Volumetric / Count	Visits Patient Fac is the count of unique patient and service date combinations across facility claims. This method for counting visits should be used when multiple facility claims can be submitted for the same visit on the same day but the visit should only be counted once.
Visits Patient Med	Constrained by Medical Claims	Visits Patient Med is the number of facility and professional visits provided under medical coverage. The number of visits is based on the count of unique patient and service date combinations.
Visits Per 1000 OP Phys	(Visits OP Phys/(Member Months Med/1000))*12	Visits Per 1000 OP Phys is the average number of outpatient professional visits provided under medical coverage that were performed by a physician, per 1000 members with medical coverage per year.
Visits Per 1000 OP Prof Med	(Visits OP Prof Med/(Member Months Med/1000))*12	Visits Per 1000 OP Prof Med is the average number of outpatient professional visits provided under medical coverage, per 1000 members with medical coverage per year. The number of visits is based on the count of unique patient, service date, and provider combinations.
Visits Per Pat Office Med	Constrained by Office Setting Medical	Visits Per Pat Office Med is the average number of visits, per patient, for professional visits provided in an office setting under medical coverage.
Visits Provider Prof	Volumetric / Count	Visits Provider Prof is the count of unique patient, service date, and provider ID combinations across professional claims. This method for counting visits should be used when multiple providers could be involved in different visits for the same patient on the same day and each should be counted as a separate visit.

File details come from the government source that posted it. Updated Sep 16, 2026.