COE_HCC_NO_PHI_25000_Current.pdf
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- Attached to
- Pharmacy Benefits 2025-2026
- Solicitation number
- 2025-011
- Issued by
- Hidalgo County, Texas
About this file
This document is a detailed claims data report for the City of Edinburg's health insurance program, covering high-cost claims from October 2024 to April 2025. The report analyzes 27 individual claims with medical and pharmacy paid expenses, categorized by member relationship, age/gender, benefit package, and primary diagnosis. The high-cost threshold is set at $25,000, and the report covers facility inpatient, facility outpatient, professional, and pharmacy service categories for subscribers, spouses, and dependent children enrolled in PPO ACTIVE and PPO RETIREE PRE 65 benefit packages.
The total paid claims amount is $1,920,459.42, with $1,438,873.65 in medical expenses and $481,585.77 in pharmacy expenses. The claims represent diverse medical conditions, including non-Hodgkin's lymphoma, multiple sclerosis, kidney calculus, malignant neoplasms, and various other diagnoses across different age groups. Most members are enrolled in PPO ACTIVE plans, with a few in HMO and RETIREE PRE 65 packages. Only one claim is noted as COVID-19 confirmed, and the report provides a comprehensive breakdown of individual medical expenses, pharmacy costs, and primary diagnoses for each claimant.
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Text version
COE HCC NO PHI 25000_Current
Run Date: 6/5/2025
Metrics:
Database:
High Cost Threshold:
Paid Month:
Service Category:
Member Relationship DescriptionMember Age/Gender BandCurrently Enrolled IndicatorBenefit PackageMedical Paid Pharmacy Paid Paid Primary Diagnosis COVID-19 Confirmed
Subscriber Male 40-49 Yes PPO ACTIVE 306,281.93 10,205.67 316,487.60 C83 - Diffuse non-
Hodgkin's lymphoma
No
Dependent Child Male <1-19 No PPO ACTIVE 169,745.73 0.00 169,745.73 P07 - Disorders related to short gestation and low birth weight, not elsewhere classified
No
Spouse Male 40-49 Yes PPO ACTIVE 142,581.99 1,352.03 143,934.02 Z51 - Other medical care
Yes
Subscriber Female 50-59 YesPPO RETIREE PRE 65 13,142.54 109,385.37 122,527.91 Z08 - Follow-up examination after treatment for malignant neoplasms
No
Dependent Child Female <1-19 Yes PPO ACTIVE 110,348.59 0.00 110,348.59 S42 - Fracture of shoulder and upper arm
No
Subscriber Male 40-49 Yes PPO ACTIVE 83,079.30 104.98 83,184.28 G35 - Multiple sclerosis No
Subscriber Male 50-59 Yes HMO ACTIVE 70,319.47 9,541.79 79,861.26 N20 - Calculus of kidney and ureter
No
Subscriber Male 40-49 Yes PPO ACTIVE 64,261.72 10,981.12 75,242.84 C20 - Malignant neoplasm of rectum
No
Subscriber Female 50-59 YesPPO RETIREE PRE 65 1,633.81 71,168.39 72,802.20 M54 - Dorsalgia No
Subscriber Female 50-59 Yes PPO ACTIVE 66,966.47 3,901.97 70,868.44 A41 - Other septicaemia No
Subscriber Female 40-49 Yes PPO ACTIVE 800.18 50,918.74 51,718.92 L40 - Psoriasis No
Dependent Child Male <1-19 Yes PPO ACTIVE 51,622.09 13.30 51,635.39 Q66 - Congenital deformities of feet
Yes
Subscriber Male 60-64 YesHMO RETIREE PRE 65 46,706.33 2,986.81 49,693.14 C20 - Malignant neoplasm of rectum
No
Subscriber Male 40-49 Yes PPO ACTIVE 3,993.77 44,004.20 47,997.97 J45 - Asthma No
Dependent Child Male <1-19 Yes PPO ACTIVE 376.92 46,653.35 47,030.27 E23 - Hypofunction and other disorders of pituitary gland
No
(Paid)
(CITY OF EDINBURG 000243483: ALL)
($25,000)
(Oct 2024 - Apr 2025)
(FACILITY INPATIENT, FACILITY OUTPATIENT, PROFESSIONAL, PHARMACY)
Member Relationship DescriptionMember Age/Gender BandCurrently Enrolled IndicatorBenefit PackageMedical Paid Pharmacy Paid Paid Primary Diagnosis COVID-19 Confirmed
Dependent Child Male <1-19 Yes PPO ACTIVE 46,812.27 9.48 46,821.75 A40 - Streptococcal septicaemia
No
Subscriber Female 30-39 Yes PPO ACTIVE 3,042.28 40,387.58 43,429.86 C64 - Malignant neoplasm of kidney, except renal pelvis
No
Dependent Child Male <1-19 Yes PPO ACTIVE 41,855.79 178.85 42,034.64 F84 - Pervasive developmental disorders
No
Subscriber Female 50-59 YesPPO RETIREE PRE 65 3,390.80 37,716.04 41,106.84 H25 - Senile cataract No
Spouse Female 30-39 Yes PPO ACTIVE 37,663.49 221.37 37,884.86 S83 - Dislocation, sprain and strain of joints and ligaments of knee
No
Spouse Male 65+ No PPO ACTIVE 33,476.73 0.00 33,476.73 N39 - Other disorders of urinary system
No
Dependent Child Female <1-19 Yes PPO ACTIVE 31,272.97 695.94 31,968.91 H65 - Nonsuppurative otitis media
No
Dependent Child Female <1-19 Yes PPO ACTIVE 31,468.78 0.00 31,468.78 N10 - Acute tubulo-interstitial nephritis
No
Subscriber Male 60-64 YesPPO RETIREE PRE 65 29,980.34 1,477.95 31,458.29 T83 - Complications of genitourinary devices, implants and grafts
No
Spouse Female 60-64 Yes PPO ACTIVE 747.88 29,887.08 30,634.96 G51 - Facial nerve disorders
No
Spouse Female 50-59 Yes PPO ACTIVE 20,137.99 9,673.93 29,811.92 E11 - Non-insulin-dependent diabetes mellitus
No
Subscriber Male 50-59 YesPPO RETIREE PRE 65 27,163.49 119.83 27,283.32 I34 - Nonrheumatic mitral valve disorders
No
Query Totals: 27 1,438,873.65 481,585.77 1,920,459.42
Report Totals: 27 1,438,873.65 481,585.77 1,920,459.42
COVID-19 Confirmed
COVID-19 Confirmed
File details come from the government source that posted it. Updated .