ESBD_360338_1716477847276_Attachment D.3 - Large Loss Claim Payments CY 2021-March 2024.pdf
PDF 240 KB Posted
- Solicitation number
- RFp2024-P11
- Issued by
- Hays County, Texas
About this file
This document contains large loss claim payment details for a medical insurance policy held by Hays County (the County) through UnitedHealthcare. The report covers claim payments made in calendar years 2021 through March 2024, and includes information on the subscriber, their relationship, employment status, Medicare status, policy number, account product, and total payments.
The related state and local contract opportunity is an RFP issued by Hays County for Employee Group Health, Dental, and Employee Assistance Plans. The County is seeking proposals from qualified companies to provide a comprehensive benefits package including medical, pharmacy, dental, and employee wellness/assistance plan, with the intent to implement the chosen plans effective January 1, 2025. The County is looking to partner with an insurance provider that can offer competitive long-term and stable financial solutions while providing a robust benefits package.
View the file
Other files
Show all 23
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Large Loss Claim Payments
CY 2021
Report Filter:
Claimant Relationship Subscriber Employment Status
Medicare Status '-Policy Number Suffix Account Product HMO Account Division Payments
AF 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $588,635.01
AL 0000 Individual Health Pooling NOT APPLICABLE - NON-HMO PRODUCT ($19,827.33)
Total $568,807.68
AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $235,249.82
AL 0000 Individual Health Pooling NOT APPLICABLE - NON-HMO PRODUCT ($14,028.89)
Total $221,220.93
AF 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $327,724.19
AL 0000 Individual Health Pooling NOT APPLICABLE - NON-HMO PRODUCT ($124,537.97)
Total $203,186.22
AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $1,089,324.86
AL 0000 Individual Health Pooling NOT APPLICABLE - NON-HMO PRODUCT ($886,978.71)
Total $202,346.15
AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $407,057.25
AL 0000 Individual Health Pooling NOT APPLICABLE - NON-HMO PRODUCT ($217,246.11)
Total $189,811.14
AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $171,098.19
AL 0000 Individual Health Pooling NOT APPLICABLE - NON-HMO PRODUCT ($210.44)
Total $170,887.75
Subscriber Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $161,316.49JAMES
BONNY
Subscriber Active Non-Medicare 000912772
PABLO
Subscriber Active Non-Medicare 000912772
BRANDON
Subscriber Active Non-Medicare 000912772
ALEXI
Subscriber Active Non-Medicare 000912772
({Service Year/Month} = 2021-12, 2021-11, 2021-10, 2021-09, 2021-08, 2021-07, 2021-06, 2021-05, 2021-04, 2021-03, 2021-02, 2021-01) And ({Claimant ID} (ID) <> "9999999999999999") And ({-Policy Number} = 000912772) And ({Benefit Type Category} = Medical Benefit , Managed Pharmacy Benefit ) And ({Funding Arrangement Category} = Administrative Services Only) And (Set of Claimant ID where {Total Payments for Dollar Threshold} > 50000)
GREGORY
Subscriber Active Non-Medicare 000912772
TYLER
Child Active Non-Medicare 000912772
Total $161,316.49
Spouse Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $161,101.69
Total $161,101.69
Active Non-Medicare 000912772 AE 0004 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $159,928.72
Retired Non-Medicare 000912772 AE 0004 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $0.44
Total $159,929.16
AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $1,692,456.83
AL 0000 Individual Health Pooling NOT APPLICABLE - NON-HMO PRODUCT ($1,543,582.73)
Total $148,874.10
Spouse Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $142,057.76
Total $142,057.76
Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $112,653.93
Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $16,611.93
Unknown 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $0.00
Total $129,265.86
Non-Medicare 000912772 AD 0003 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $126,763.16
Medicare 000912772 AD 0003 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $2,417.59
Total $129,180.75
Retired Subscriber Retired Medicare 000912772 AD 0004 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $108,258.61
Total $108,258.61
Spouse Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $104,733.27
Total $104,733.27
Non-Medicare 000912772 AD 0004 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $94,953.84
Medicare 000912772 AD 0004 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $7,734.99
LAUREL
ELIZABETH
TERRI
Spouse Retired
Non-Medicare 000912772
CAROL
FRANCES
Spouse Active
ROSE
Subscriber Active
MARIA
ENRIQUE
Subscriber
DUSTIN
Subscriber Active
Total $102,688.83
AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $100,423.19
AL 0000 Individual Health Pooling NOT APPLICABLE - NON-HMO PRODUCT $276.00
Total $100,699.19
Subscriber Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $95,698.14
Total $95,698.14
Subscriber Active Non-Medicare 000912772 AD 0005 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $94,919.09
Total $94,919.09
Child Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $87,918.86
Total $87,918.86
Subscriber Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $83,918.39
Total $83,918.39
AE 0004 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $141,687.77
AL 0000 Individual Health Pooling NOT APPLICABLE - NON-HMO PRODUCT ($65,820.84)
Retired Non-Medicare 000912772 AE 0004 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $7,799.18
Total $83,666.11
Subscriber Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $81,490.10
Total $81,490.10
Non-Medicare 000912772 AE 0003 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $72,597.16
Medicare 000912772 AE 0003 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $5,569.91
Total $78,167.07
Retired Subscriber Retired Non-Medicare 000912772 AD 0004 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $75,162.88
Total $75,162.88
Subscriber Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $75,036.01
Total $75,036.01
ROCIO
FRANCES
Subscriber Active
BETTY
JAZMIN
Non-Medicare 000912772
SUSANA
ROSARIO
LAYLA
JESSE
ALBERT
Subscriber
Active Non-Medicare 000912772
AXXTON
Child Active
Subscriber Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $74,082.20
Total $74,082.20
Child Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $69,408.64
Total $69,408.64
Subscriber Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $67,436.02
Total $67,436.02
Retired Subscriber Retired Medicare 000912772 AD 0004 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $66,992.58
Total $66,992.58
Subscriber Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $66,501.85
Total $66,501.85
Spouse Active Non-Medicare 000912772 AD 0003 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $66,481.25
Total $66,481.25
Subscriber Active Non-Medicare 000912772 AD 0005 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $65,712.20
Total $65,712.20
Subscriber Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $64,456.07
Total $64,456.07
Subscriber Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $62,631.10
Total $62,631.10
Subscriber Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $62,055.23
Total $62,055.23
Subscriber Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $62,052.11
Total $62,052.11
Active Non-Medicare 000912772 AE 0004 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $3,246.18
Retired Non-Medicare 000912772 AE 0004 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $54,599.41
Total $57,845.59
MARYANN
Subscriber
DEBBIE
JAMES
REGINALD
TRICIA
HEIDI
BILLY
LETICIA
BOBBY
CELESTE
ERIC
MARTIN
Subscriber Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $57,073.42
Total $57,073.42
Subscriber Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $56,104.42
Total $56,104.42
Spouse Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $52,958.84
Total $52,958.84
Subscriber Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $52,731.66
Total $52,731.66
Subscriber Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $50,841.37
Total $50,841.37
Spouse Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $50,760.45
Total $50,760.45 Total $4,866,467.23
This document contains UnitedHealthcare’s confidential and/or proprietary business information (PBI). PBI may only be used by the recipient person/entity to which it is addressed. Recipient is liable for using and protecting UnitedHealthcare’s PBI from further disclosure or misuse, consistent with recipient’s contractual obligations under any applicable administrative services agreement, group policy contract, non-disclosure agreement or other applicable contract or law, including but not limited to the U.S. Freedom of Information Act and state freedom of information law exemptions for “trade secrets”. The document may also contain protected health information (PHI) and must be handled according to applicable state and federal law, including, but not limited to HIPAA. Recipients who misuse information may be subject to both civil and criminal penalties.
RACHEL
MINDI
JULIAN
MARY
JEFFREY
JEANINE
CY 2022
Report Filter:
Claimant RelationshipSubscriber Employment Status Medicare Status '-Policy Number Suffix Account Product HMO Account Division Payments
Subscriber Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1)
NOT APPLICABLE - NON-HMO
PRODUCT $254,470.90
Total $254,470.90
AE 0002 EPO Choice (EP1)
NOT APPLICABLE - NON-HMO
PRODUCT $242,066.54
AL 0000 Individual Health Pooling
NOT APPLICABLE - NON-HMO
PRODUCT ($34,812.56)
Total $207,253.98
AE 0002 EPO Choice (EP1)
NOT APPLICABLE - NON-HMO
PRODUCT $450,789.36
AL 0000 Individual Health Pooling
NOT APPLICABLE - NON-HMO
PRODUCT ($250,789.36)
Total $200,000.00
Subscriber Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1)
NOT APPLICABLE - NON-HMO
PRODUCT $194,017.43
Total $194,017.43
Child Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1)
NOT APPLICABLE - NON-HMO
PRODUCT $156,985.74
Total $156,985.74
Spouse Retired Medicare 000912772 AD 0004 POS Choice Plus (PS1)
NOT APPLICABLE - NON-HMO
PRODUCT $132,231.44
Total $132,231.44
Subscriber Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1)
NOT APPLICABLE - NON-HMO
PRODUCT $128,479.04
Total $128,479.04
Child Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1)
NOT APPLICABLE - NON-HMO
PRODUCT $127,736.23
Total $127,736.23
Subscriber Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1)
NOT APPLICABLE - NON-HMO
PRODUCT $124,341.34
Total $124,341.34
Retired Subscriber Retired Medicare 000912772 AD 0004 POS Choice Plus (PS1)
NOT APPLICABLE - NON-HMO
PRODUCT $122,377.60
Total $122,377.60
Child Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1)
NOT APPLICABLE - NON-HMO
PRODUCT $119,469.13
({Service Year/Month} = 2022-12, 2022-11, 2022-10, 2022-09, 2022-08, 2022-07, 2022-06, 2022-05, 2022-04, 2022-03, 2022-02, 2022-01) And ({Claimant ID} (ID) <> "9999999999999999") And ({-Policy Number} = 000912772) And ({Benefit Type Category} = Medical Benefit , Managed Pharmacy Benefit ) And ({Funding Arrangement Category} = Administrative Services Only) And (Set of Claimant ID where {Total Payments for Dollar Threshold} > 50000)
REGINALD
ALAN
Subscriber Active Non-Medicare 000912772
BRIANA
Child Active Non-Medicare 000912772
PABLO
ALEJANDRO
TERRI
DIANA
ROBERT
IAN
LAUREL
MASSIMO
Total $119,469.13
Subscriber Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1)
NOT APPLICABLE - NON-HMO
PRODUCT $117,552.81
Total $117,552.81
Spouse Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1)
NOT APPLICABLE - NON-HMO
PRODUCT $113,421.10
Total $113,421.10
AD 0002 POS Choice Plus (PS1)
NOT APPLICABLE - NON-HMO
PRODUCT $102,843.94
AE 0002 EPO Choice (EP1)
NOT APPLICABLE - NON-HMO
PRODUCT $412.27
Unknown 000912772 AE 0002 EPO Choice (EP1)
NOT APPLICABLE - NON-HMO
PRODUCT $0.00
Total $103,256.21
AD 0002 POS Choice Plus (PS1)
NOT APPLICABLE - NON-HMO
PRODUCT $100,193.05
AL 0000 Individual Health Pooling
NOT APPLICABLE - NON-HMO
PRODUCT ($473.00)
Total $99,720.05
Subscriber Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1)
NOT APPLICABLE - NON-HMO
PRODUCT $97,080.78
Total $97,080.78
Non-Medicare 000912772 AD 0004 POS Choice Plus (PS1)
NOT APPLICABLE - NON-HMO
PRODUCT $76,836.23
Medicare 000912772 AD 0004 POS Choice Plus (PS1)
NOT APPLICABLE - NON-HMO
PRODUCT $17,189.78
Total $94,026.01
Subscriber Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1)
NOT APPLICABLE - NON-HMO
PRODUCT $93,452.21
Total $93,452.21
Subscriber Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1)
NOT APPLICABLE - NON-HMO
PRODUCT $85,205.44
Total $85,205.44
Spouse Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1)
NOT APPLICABLE - NON-HMO
PRODUCT $84,911.18
Total $84,911.18
Subscriber Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1)
NOT APPLICABLE - NON-HMO
PRODUCT $83,851.43
Total $83,851.43
Retired Subscriber Retired Medicare 000912772 AD 0004 POS Choice Plus (PS1)
NOT APPLICABLE - NON-HMO
PRODUCT $82,176.77
Total $82,176.77
Subscriber Active Non-Medicare 000912772 AD 0005 POS Choice Plus (PS1)
NOT APPLICABLE - NON-HMO
PRODUCT $75,252.67
TROY
JEANINE
000912772
TYLER
Child Active Non-Medicare 000912772
CELESTE
Subscriber Active
Non-Medicare
LINDA
BETTY
Retired Subscriber Retired
BURLON
MINDI
DEBORAH
LETICIA
JAMES
HEIDI
Total $75,252.67
AD 0002 POS Choice Plus (PS1)
NOT APPLICABLE - NON-HMO
PRODUCT $117,279.19
AL 0000 Individual Health Pooling
NOT APPLICABLE - NON-HMO
PRODUCT ($47,583.74)
Total $69,695.45
Child Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1)
NOT APPLICABLE - NON-HMO
PRODUCT $64,731.35
Total $64,731.35
AD 0002 POS Choice Plus (PS1)
NOT APPLICABLE - NON-HMO
PRODUCT $64,106.98
AL 0000 Individual Health Pooling
NOT APPLICABLE - NON-HMO
PRODUCT ($99.11)
Total $64,007.87
Retired Subscriber Retired Non-Medicare 000912772 AD 0004 POS Choice Plus (PS1)
NOT APPLICABLE - NON-HMO
PRODUCT $62,863.05
Total $62,863.05
Subscriber Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1)
NOT APPLICABLE - NON-HMO
PRODUCT $62,471.91
Total $62,471.91
Child Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1)
NOT APPLICABLE - NON-HMO
PRODUCT $60,844.68
Total $60,844.68
Subscriber Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1)
NOT APPLICABLE - NON-HMO
PRODUCT $59,316.87
Total $59,316.87
Subscriber Active Non-Medicare 000912772 AD 0005 POS Choice Plus (PS1)
NOT APPLICABLE - NON-HMO
PRODUCT $58,399.36
Total $58,399.36
Subscriber Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1)
NOT APPLICABLE - NON-HMO
PRODUCT $57,813.41
Total $57,813.41
Non-Medicare 000912772 AE 0003 EPO Choice (EP1)
NOT APPLICABLE - NON-HMO
PRODUCT $47,317.98
Medicare 000912772 AE 0003 EPO Choice (EP1)
NOT APPLICABLE - NON-HMO
PRODUCT $10,466.66
Unknown 000912772 AE 0003 EPO Choice (EP1)
NOT APPLICABLE - NON-HMO
PRODUCT $25.45
Total $57,810.09
Child Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1)
NOT APPLICABLE - NON-HMO
PRODUCT $57,153.96
Total $57,153.96
Child Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1)
NOT APPLICABLE - NON-HMO
PRODUCT $56,612.75
AXXTON
Child Active Non-Medicare 000912772
LAYLA
BONNY
Subscriber Active Non-Medicare 000912772
RUBEN
JESSE
JORDAN
MARK
ROSARIO
NANCY
FRANCES
Subscriber Active
TRUMANE
JONAH
Total $56,612.75
Active Non-Medicare 000912772 AD 0004 POS Choice Plus (PS1)
NOT APPLICABLE - NON-HMO
PRODUCT $53,967.13
Retired Non-Medicare 000912772 AD 0004 POS Choice Plus (PS1)
NOT APPLICABLE - NON-HMO
PRODUCT $1,734.52
Total $55,701.65
Retired Subscriber Retired Medicare 000912772 AE 0004 EPO Choice (EP1)
NOT APPLICABLE - NON-HMO
PRODUCT $55,616.23
Total $55,616.23
Subscriber Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1)
NOT APPLICABLE - NON-HMO
PRODUCT $52,068.53
Total $52,068.53 Total $3,792,376.65
JERRY
MARY
This document contains UnitedHealthcare’s confidential and/or proprietary business information (PBI). PBI may only be used by the recipient person/entity to which it is addressed. Recipient is liable for using and protecting UnitedHealthcare’s PBI from further disclosure or misuse, consistent with recipient’s contractual obligations under any applicable administrative services agreement, group policy contract, non-disclosure agreement or other applicable contract or law, including but not limited to the U.S. Freedom of Information Act and state freedom of information law exemptions for “trade secrets”. The document may also contain protected health information (PHI) and must be handled according to applicable state and federal law, including, but not limited to HIPAA. Recipients who misuse information may be subject to both civil and criminal penalties.
ROBERT
Subscriber
CY 2023
Report Filter:
Claimant Relationship Subscriber Employment Status Medicare Status '-Policy Number Suffix Account Product HMO Account Division Payments
Subscriber Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $505,484.07
Total $505,484.07
Subscriber Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $199,133.63
Total $199,133.63
Retired Subscriber Retired Non-Medicare 000912772 AD 0004 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $195,022.52
Total $195,022.52
AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $190,230.12
AL 0000 Individual Health Pooling NOT APPLICABLE - NON-HMO PRODUCT $0.00
Unknown 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $0.00
Total $190,230.12
Spouse Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $188,845.18
Total $188,845.18
0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $201,450.88
0004 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $148.61
AL 0000 Individual Health Pooling NOT APPLICABLE - NON-HMO PRODUCT ($33,754.00)
Retired Non-Medicare 000912772 AE 0004 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $19,451.24
Total $187,296.73
AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $281,415.97
AL 0000 Individual Health Pooling NOT APPLICABLE - NON-HMO PRODUCT ($101,359.67)
Total $180,056.30
Child Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $167,984.44
Total $167,984.44
Spouse Retired Non-Medicare 000912772 AE 0004 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $165,840.34
Total $165,840.34
Subscriber Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $165,041.29
Total $165,041.29
Spouse Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $151,135.72
Total $151,135.72
Child Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $140,632.87
Total $140,632.87
({Service Year/Month} = 2023-11, 2023-12, 2023-10, 2023-09, 2023-08, 2023-07, 2023-06, 2023-05, 2023-04, 2023-03, 2023-02, 2023-01) And ({Claimant ID} (ID) <> "9999999999999999") And ({-Policy Number} = 000912772) And ({Benefit Type Category} = Medical Benefit , Managed Pharmacy Benefit ) And ({Funding Arrangement Category} = Administrative Services Only) And (Set of Claimant ID where {Total Payments for Dollar Threshold} > 50000)
ROSALINDA
IAN
THOMAS
STANLEY
Subscriber Active
Non-Medicare 000912772
SUE ANN
000912772
AE
TYLER
Child Active Non-Medicare 000912772
PABLO
Subscriber
Active Non-Medicare
ROBERT
ESTER
CELESTE
DAVID
RILEY
Subscriber Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $126,009.10
Total $126,009.10
Child Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $122,796.51
Total $122,796.51
Subscriber Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $114,278.77
Total $114,278.77
Spouse Retired Medicare 000912772 AD 0004 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $110,664.75
Total $110,664.75
Retired Subscriber Retired Medicare 000912772 AD 0004 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $110,570.93
Total $110,570.93
Subscriber Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $105,994.61
Total $105,994.61
Spouse Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $100,358.50
Total $100,358.50
Subscriber Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $99,388.64
Total $99,388.64
Subscriber Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $91,262.99
Total $91,262.99
Subscriber Active Non-Medicare 000912772 AD 0005 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $84,802.67
Total $84,802.67
AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $107,972.41
AL 0000 Individual Health Pooling NOT APPLICABLE - NON-HMO PRODUCT ($25,870.91)
Total $82,101.50
Child Retired Non-Medicare 000912772 AD 0004 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $80,803.21
Total $80,803.21
Retired Subscriber Retired Non-Medicare 000912772 AD 0004 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $79,046.00
Total $79,046.00
Retired Subscriber Retired Medicare 000912772 AD 0004 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $78,354.48
Total $78,354.48
Subscriber Active Non-Medicare 000912772 AF 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $73,704.75
Total $73,704.75
Subscriber Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $72,169.84
Total $72,169.84
Subscriber Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $71,328.68
Total $71,328.68
Subscriber Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $70,890.61
Total $70,890.61
Active Non-Medicare 000912772 AE 0004 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $69,507.68
DIANA
AVREY
DANNY
TERRI
JAMES
LISA
KATHRYN
RANDY
MINDI
HEIDI
000912772
SETH
ROSANNA
DARRELL
JAMES
AXXTON
Child Active Non-Medicare
LETICIA
DAVID
MARK
Subscriber
Retired Non-Medicare 000912772 AE 0004 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $283.89
Total $69,791.57
Subscriber Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $65,649.20
Total $65,649.20
Subscriber Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $65,293.93
Total $65,293.93
Retired Subscriber Retired Medicare 000912772 AD 0004 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $63,518.34
Total $63,518.34
Spouse Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $63,022.79
Total $63,022.79
Spouse Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $61,642.39
Total $61,642.39
Child Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $61,432.46
Total $61,432.46
AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $132.94
AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $58,923.39
Unknown 000912772 AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $2,355.95
Total $61,412.28
Subscriber Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $58,614.75
Total $58,614.75
Subscriber Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $57,759.67
Total $57,759.67
Subscriber Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $54,503.45
Total $54,503.45
Spouse Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $52,607.54
Total $52,607.54 Total $4,846,478.12
ROBERTO
Subscriber
FREDERIC
SYLVIA
BETTY
MICHELLE
DEBORAH
JORDAN
JESSE
Subscriber
MARY
STEPHEN
This document contains UnitedHealthcare’s confidential and/or proprietary business information (PBI). PBI may only be used by the recipient person/entity to which it is addressed. Recipient is liable for using and protecting UnitedHealthcare’s PBI from further disclosure or misuse, consistent with recipient’s contractual obligations under any applicable administrative services agreement, group policy contract, non-disclosure agreement or other applicable contract or law, including but not limited to the U.S. Freedom of Information Act and state freedom of information law exemptions for “trade secrets”. The document may also contain protected health information (PHI) and must be handled according to applicable state and federal law, including, but not limited to HIPAA. Recipients who misuse information may be subject to both civil and criminal penalties.
Active Non-Medicare 000912772
LARRY
MATTHEW
Jan-March 2024 Report Filter:
Claimant Relationship Subscriber Employment Status Medicare Status '-Policy Number Suffix Account Product HMO Account Division Payments
AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $487,462.80
AL 0000 Individual Health Pooling NOT APPLICABLE - NON-HMO PRODUCT ($287,899.66)
Total $199,563.14
Active Non-Medicare 000912772 AF 0004 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $81,852.78
Retired Non-Medicare 000912772 AF 0004 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $127.39
Total $81,980.17
Subscriber Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $76,094.19
Total $76,094.19
Subscriber Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $56,767.00
Total $56,767.00
Child Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $55,442.94
Total $55,442.94
Subscriber Active Non-Medicare 000912772 AF 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $47,218.51
Total $47,218.51
Spouse Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $45,978.37
Total $45,978.37
0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $703.61
0004 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $22.40
Retired Non-Medicare 000912772 AE 0004 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $42,964.79
Total $43,690.80
({Book Year/Month} = 2024-03, 2024-02, 2024-01) And ({Claimant ID} (ID) <> "9999999999999999") And ({-Policy Number} = 000912772) And ({Benefit Type Category} = Medical Benefit , Managed Pharmacy Benefit ) And ({Funding Arrangement Category} = Administrative Services Only) And (Set of Claimant ID where {Total Payments for Dollar Threshold} > 20000)
AE
Subscriber
Active Non-Medicare 000912772
IAN
ROBERT
LAURA
STEPHEN
PABLO
000912772
KERRI
Spouse
RANDY
ROSALINDA
Subscriber Active Non-Medicare
Subscriber Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $39,765.26
Total $39,765.26
Subscriber Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $37,704.26
Total $37,704.26
AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $32,539.71
AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $682.09
Total $33,221.80
Child Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $32,696.07
Total $32,696.07
Subscriber Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $32,253.51
Total $32,253.51
Subscriber Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $31,948.76
Total $31,948.76
Subscriber Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $31,574.90
Total $31,574.90
Child Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $29,998.03
Total $29,998.03
Subscriber Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $29,164.99
Total $29,164.99
Subscriber Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $28,317.30
Total $28,317.30
Subscriber Active Non-Medicare 000912772 AE 0005 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $26,164.42
Total $26,164.42
Spouse Retired Medicare 000912772 AD 0004 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $25,780.87
Total $25,780.87
DEBBIE
MINDI
RENEE
TERRI
KASSADIE
AURORA
LISA
WILLIAM
GRADY
FREDERIC
WINTON
ALFREDO
Subscriber Active Non-Medicare 000912772
Subscriber Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $24,435.48
Total $24,435.48
AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $24,390.54
AL 0000 Individual Health Pooling NOT APPLICABLE - NON-HMO PRODUCT $37.56
Total $24,428.10
Retired Subscriber Retired Medicare 000912772 AD 0004 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $24,201.69
Total $24,201.69
Subscriber Active Non-Medicare 000912772 AD 0005 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $23,245.86
Total $23,245.86
Subscriber Active Non-Medicare 000912772 AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $21,797.62
Total $21,797.62
Child Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $21,571.81
Total $21,571.81
Spouse Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $20,904.93
Total $20,904.93
Spouse Active Non-Medicare 000912772 AE 0002 EPO Choice (EP1) NOT APPLICABLE - NON-HMO PRODUCT $20,680.28
Total $20,680.28
Retired Subscriber Retired Medicare 000912772 AD 0004 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $20,197.73
Total $20,197.73
Retired Subscriber Retired Medicare 000912772 AD 0004 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $20,130.11
Total $20,130.11
AD 0002 POS Choice Plus (PS1) NOT APPLICABLE - NON-HMO PRODUCT $19,666.84
AL 0000 Individual Health Pooling NOT APPLICABLE - NON-HMO PRODUCT $393.39
Total $20,060.23 Total $1,226,979.13
Child Active Non-Medicare 000912772
COURTNEY
BRANDACE
BETTY
PATRICIA
TYLER
000912772
JAMES
HEIDI
CELESTE
CALLIE
AXXTON
Child Active Non-Medicare
DIANA
This document contains UnitedHealthcare’s confidential and/or proprietary business information (PBI). PBI may only be used by the recipient person/entity to which it is addressed. Recipient is liable for using and protecting UnitedHealthcare’s PBI from further disclosure or misuse, consistent with recipient’s contractual obligations under any applicable administrative services agreement, group policy contract, non-disclosure agreement or other applicable contract or law, including but not limited to the U.S. Freedom of Information Act and state freedom of information law exemptions for “trade secrets”. The document may also contain protected health information (PHI) and must be handled according to applicable state and federal law, including, but not limited to HIPAA. Recipients who misuse information may be subject to both civil and criminal penalties.
Large Loss Claim Payments
File details come from the government source that posted it. Updated .