COE_HCC_NO_PHI_100000_2022-2023.pdf
PDF 45 KB Posted
- Attached to
- Pharmacy Benefits 2025-2026
- Solicitation number
- 2025-011
- Issued by
- Hidalgo County, Texas
About this file
This document is a high-cost claims report for the City of Edinburg's health insurance program, covering the period from October 2022 to September 2023. The report details 11 individual medical claims exceeding $100,000, categorized by member relationship, age/gender band, enrollment status, benefit package, and primary diagnosis. The claims data encompasses medical and pharmacy paid amounts, totaling $2,093,722.76 across various benefit packages including PPO Active, HMO Active, and Retiree Pre-65 plans.
The claims reflect a diverse range of medical conditions, including multiple malignant neoplasms (cancers), congenital conditions, bacterial infections, and other medical diagnoses. The highest individual claim is $342,723.65 for a male subscriber aged 50-59 with a PPO Active plan, while the lowest reported claim is $102,268.36 for a male subscriber aged 40-49. Notably, none of the claims are marked as COVID-19 confirmed, and the pharmacy paid amounts vary significantly across different members, ranging from $0 to $168,714.10. The report provides a comprehensive overview of high-cost healthcare utilization for the City of Edinburg's insurance program.
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Text version
COE HCC NO PHI 100000_2022-2023
Run Date: 6/5/2025
Metrics:
Database:
High Cost
Threshold:
Paid Month:
Service Category:
Member Relationship DescriptionMember Age/Gender BandCurrently Enrolled IndicatorBenefit Package Medical Paid Pharmacy Paid Paid Primary Diagnosis COVID-19 Confirmed
Subscriber Male 50-59 No PPO ACTIVE 181,540.24 161,183.41 342,723.65 D64 - Other anaemias
No
Subscriber Male 20-29 Yes PPO ACTIVE 317,848.22 110.13 317,958.35 Z51 - Other medical care
No
Subscriber Male 50-59 No HMO ACTIVE 250,717.15 1,040.11 251,757.26 G00 - Bacterial meningitis, not elsewhere classified
No
Subscriber Male 50-59 No HMO ACTIVE 215,825.64 19,391.51 235,217.15 C25 - Malignant neoplasm of pancreas
No
Subscriber Female 50-59 YesPPO RETIREE PRE 65 9,326.16 168,714.10 178,040.26 C90 - Multiple myeloma and malignant plasma cell neoplasms
No
Subscriber Female 30-39 No PPO ACTIVE 164,924.88 0.00 164,924.88 C78 - Secondary malignant neoplasm of respiratory and digestive organs
No
Dependent Child Male <1-19 No PPO ACTIVE 144,804.17 0.00 144,804.17 Z38 - Liveborn infants according to place of birth
No
Subscriber Male 65+ Yes PPO ACTIVE 121,696.27 12,697.23 134,393.50 M86 - Osteomyelitis No
Dependent Child Male <1-19 No PPO ACTIVE 112,916.61 0.00 112,916.61 Q23 - Congenital malformations of aortic and mitral valves
No
(Paid)
(CITY OF EDINBURG 000243483: ALL)
($100,000)
(Oct 2022 - Sep 2023)
(FACILITY INPATIENT, FACILITY OUTPATIENT, PROFESSIONAL, PHARMACY)
Member Relationship DescriptionMember Age/Gender BandCurrently Enrolled IndicatorBenefit Package Medical Paid Pharmacy Paid Paid Primary Diagnosis COVID-19 Confirmed
Dependent Child Female <1-19 No HMO ACTIVE 108,718.57 0.00 108,718.57 Z38 - Liveborn infants according to place of birth
No
Subscriber Male 40-49 Yes PPO ACTIVE 101,729.67 538.69 102,268.36 C18 - Malignant neoplasm of colon
No
Query Totals: 11 1,730,047.58 363,675.18 2,093,722.76
Report Totals: 11 1,730,047.58 363,675.18 2,093,722.76
COVID-19 Confirmed
COVID-19 Confirmed
File details come from the government source that posted it. Updated .