ESBD_540156_1784577532519_Exhibit A-5 Medical Large Claims Report.xlsx
XLSX spreadsheet 27 KB Posted
- Attached to
- RFP 2607-002 Stop Loss Insurance
- Solicitation number
- 2607002
- Issued by
- Travis County, Austin City, Texas
About this file
This file contains Medical Large Claims Reports for Travis County Healthcare District, documenting catastrophic and high-cost medical claims data across three distinct reporting periods. The reports track individual claimants with significant healthcare expenditures, categorizing claims by diagnosis code, service type, and relationship to the subscriber (child, spouse, or subscriber).
The 2026 report (January 1 – April 30, 2026, current data with no lag) identifies the top 28 high-cost claimants, with the largest claim totaling $424,942 for severe protein-calorie malnutrition in a child and ranging down to $52,518 for hallux valgus treatment. The 2025 report (March 1 – December 31, 2025, with two-month lag) documents 18 catastrophic claimants with a combined total of $4,683,954.92 in medical and pharmacy claims, with the highest individual claim at $568,034 for hereditary factor VIII deficiency. The 2024 report (March 1, 2024 – February 28, 2025, with two-month lag) shows 17 catastrophic claimants totaling $4,096,395 in claims, with the largest claim at $662,102 also for hereditary factor VIII deficiency. These reports provide detailed breakdowns of inpatient versus ambulatory services, pharmacy versus medical expenses, and pooled risk allocations, indicating comprehensive claims analysis supporting stop loss insurance underwriting and rate development for the healthcare district's employee health plan.
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| TRAVIS COUNTY HEALTHCARE DISTRICT - CENT - 0000000097013764 |
| Current Data For Claims Paid January 01, 2026 - April 30, 2026 (no lag) |
Large Claimant Report
| Claimant | Total Medical/RX | ||||||
| Paid Amount | Pharmacy | ||||||
| Paid Amount | Medical | ||||||
| Paid Amount | Pooled Risk | Description | Relationship | ||||
| 1 | $424,942 | $71 | $390,680 | $34,191 | Unspecified Severe Protein-calorie Malnutrition | Child | |
| 2 | $364,309 | $1 | $287,428 | $76,880 | Acute Transverse Myelitis In Demyelinating Disease Of Central Nervous System | Child | |
| 3 | $268,352 | $18,930 | $249,423 | $0 | Sepsis, Unspecified Organism | Spouse | |
| 4 | $263,343 | $114,006 | $0 | $149,336 | Hereditary Factor Viii Deficiency | Child | |
| 5 | $158,015 | $2,381 | $86,489 | $69,145 | Gaucher Disease | Spouse | |
| 6 | $150,103 | $0 | $150,103 | $0 | Restricted Diagnosis | Child | |
| 7 | $146,023 | $54,829 | $22,181 | $69,013 | Spinal Stenosis, Cervical Region | Spouse | |
| 8 | $117,973 | $56,707 | $14,061 | $47,205 | Restricted Diagnosis | Subscriber | |
| 9 | $114,513 | $2,065 | $112,448 | $0 | Malignant Neoplasm Of Upper-outer Quadrant Of Left Female Breast | Subscriber | |
| 10 | $111,462 | $360 | $111,103 | $0 | Acute Ischemic Heart Disease, Unspecified | Subscriber | |
| 11 | $107,646 | $27,977 | $25,531 | $54,138 | Monoclonal Gammopathy | Subscriber | |
| 12 | $98,322 | $94,628 | $3,694 | $0 | Encounter For Screening For Malignant Neoplasm Of Colon | Subscriber | |
| 13 | $91,466 | $89,617 | $1,849 | $0 | Chest Pain, Unspecified | Spouse | |
| 14 | $89,373 | $87,419 | $1,954 | $0 | Chest Pain, Unspecified | Subscriber | |
| 15 | $82,633 | $180 | $82,453 | $0 | Autistic Disorder | Child | |
| 16 | $76,746 | $0 | $76,746 | $0 | Dehydration | Child | |
| 17 | $73,472 | $70,743 | $2,729 | $0 | Secondary Malignant Neoplasm Of Bone | Subscriber | |
| 18 | $73,403 | $0 | $73,403 | $0 | Autistic Disorder | Child | |
| 19 | $72,663 | $0 | $72,663 | $0 | Autistic Disorder | Child | |
| 20 | $72,562 | $0 | $72,562 | $0 | Single Liveborn Infant, Delivered By Cesarean | Child | |
| 21 | $68,524 | $298 | $68,226 | $0 | Sepsis, Unspecified Organism | Subscriber | |
| 22 | $65,832 | $64,788 | $1,045 | $0 | Multiple Sclerosis | Subscriber | |
| 23 | $65,315 | $30,305 | $1,221 | $33,789 | Calculus Of Gallbladder Without Cholecystitis Without Obstruction | Subscriber | |
| 24 | $62,778 | $0 | $62,778 | $0 | Dehydration | Child | |
| 25 | $60,529 | $59,713 | $816 | $0 | Attention-deficit Hyperactivity Disorder, Unspecified Type | Child | |
| 26 | $55,878 | $52,270 | $3,608 | $0 | Malignant Neoplasm Of Upper-outer Quadrant Of Right Female Breast | Subscriber | |
| 27 | $53,290 | $50,545 | $2,745 | $0 | Contact With And (suspected) Exposure To Infections With A Predominantly Sexual Mode Of Transmission | Subscriber | |
| 28 | $52,518 | $302 | $52,216 | $0 | Hallux Valgus (acquired), Right Foot | Subscriber |
| TRAVIS COUNTY HEALTHCARE DISTRICT - CENT - 0000000097013764 |
| Current Data For Claims Incurred March 01, 2025 - December 31, 2025 with 2 months lag |
Catastrophic Claimant Detail by Medical and Pharmacy by Diagnosis Code
| Claimant | Total Medical/RX | ||||||||
| Paid Amount | Pharmacy | ||||||||
| Paid Amount | Medical | ||||||||
| Paid Amount | Inpatient | ||||||||
| Paid Amount | Ambulatory | ||||||||
| Paid Amount | Diagnosis | ||||||||
| Code | Description | Service Rendered in Last Quarter | |||||||
| 1 | $568,034 | $567,573 | $460 | $0 | $460 | D66 | HEREDITARY FACTOR VIII DEFICIENCY | Yes | |
| 2 | $544,010 | $81,619 | $462,391 | $303,859 | $158,532 | M48.02 | SPINAL STENOSIS, CERVICAL REGION | Yes | |
| 3 | $417,022 | $356,896 | $60,126 | $0 | $60,126 | B20 | HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE | Yes | |
| 4 | $410,324 | $24,300 | $386,025 | $0 | $386,025 | E75.22 | GAUCHER DISEASE | Yes | |
| 5 | $287,804 | $77,385 | $210,419 | $0 | $210,419 | D47.2 | MONOCLONAL GAMMOPATHY | Yes | |
| 6 | $282,601 | $18,110 | $264,491 | $195,731 | $68,760 | I63.9 | CEREBRAL INFARCTION, UNSPECIFIED | Yes | |
| 7 | $270,558 | $252,407 | $18,151 | $0 | $18,151 | R55 | SYNCOPE AND COLLAPSE | Yes | |
| 8 | $201,004 | $545 | $200,459 | $0 | $200,459 | F84.0 | AUTISTIC DISORDER | Yes | |
| 9 | $195,091 | $192,852 | $2,239 | $320 | $1,919 | K52.9 | NONINFECTIVE GASTROENTERITIS AND COLITIS, UNSPECIFIED | Yes | |
| 10 | $194,815 | $182,800 | $12,014 | $0 | $12,014 | C50.411 | MALIG NEOPLM OF UPPER-OUTER QUADRANT OF RIGHT FEMALE BREAST | Yes | |
| 11 | $188,839 | $178,840 | $9,998 | $0 | $9,998 | C50.411 | MALIG NEOPLM OF UPPER-OUTER QUADRANT OF RIGHT FEMALE BREAST | Yes | |
| 12 | $166,616 | $145,288 | $21,329 | $96 | $21,232 | R07.9 | CHEST PAIN, UNSPECIFIED | Yes | |
| 13 | $164,702 | $161,888 | $2,814 | $0 | $2,814 | K52.89 | OTHER SPECIFIED NONINFECTIVE GASTROENTERITIS AND COLITIS | Yes | |
| 14 | $162,736 | $0 | $162,736 | $0 | $162,736 | F84.0 | AUTISTIC DISORDER | Yes | |
| 15 | $162,371 | $0 | $162,371 | $0 | $162,371 | F84.0 | AUTISTIC DISORDER | Yes | |
| 16 | $161,653 | $158,239 | $3,414 | $0 | $3,414 | G35 | MULTIPLE SCLEROSIS | Yes | |
| 17 | $154,720 | $4 | $154,716 | $149,829 | $4,887 | G82.20 | PARAPLEGIA, UNSPECIFIED | Yes | |
| 18 | $151,055 | $150,376 | $679 | $0 | $679 | R09.89 | OTH SYMPTOMS AND SIGNS INVOLVING THE CIRC AND RESP SYSTEMS | Yes | |
| Total | 4683954.92 | 2549122.94 | 2134831.98 | 649835.24 | 1484996.74 |
| TRAVIS COUNTY HEALTHCARE DISTRICT - CENT - 0000000097013764 | |||||||||
| Current Data For Claims Incurred March 01, 2024 - February 28, 2025 with 2 months lag | |||||||||
| Catastrophic Claimant Detail by Medical and Pharmacy by Diagnosis Code | |||||||||
| Claimant | Total Medical/RX | ||||||||
| Paid Amount | Pharmacy | ||||||||
| Paid Amount | Medical | ||||||||
| Paid Amount | Inpatient | ||||||||
| Paid Amount | Ambulatory | ||||||||
| Paid Amount | Diagnosis | ||||||||
| Code | Description | Service Rendered in Last Quarter | |||||||
| 1 | $662,102 | $661,749 | $354 | $0 | $354 | D66 | HEREDITARY FACTOR VIII DEFICIENCY | Yes | |
| 2 | $357,456 | $228 | $357,228 | $347,256 | $9,972 | A41.9 | SEPSIS, UNSPECIFIED ORGANISM | No | |
| 3 | $304,652 | $0 | $304,652 | $304,652 | $0 | Z38.01 | SINGLE LIVEBORN INFANT, DELIVERED BY CESAREAN | No | |
| 4 | $300,520 | $290,027 | $10,492 | $0 | $10,492 | C90.00 | MULTIPLE MYELOMA NOT HAVING ACHIEVED REMISSION | Yes | |
| 5 | $298,958 | $14,475 | $284,482 | $281,097 | $3,385 | I21.4 | NON-ST ELEVATION (NSTEMI) MYOCARDIAL INFARCTION | Yes | |
| 6 | $251,635 | $222,271 | $29,364 | $0 | $29,364 | C34.11 | MALIGNANT NEOPLASM OF UPPER LOBE, RIGHT BRONCHUS OR LUNG | Yes | |
| 7 | $196,363 | $0 | $196,363 | $0 | $196,363 | F84.0 | AUTISTIC DISORDER | Yes | |
| 8 | $193,723 | $177,467 | $16,255 | $0 | $16,255 | C50.411 | MALIG NEOPLM OF UPPER-OUTER QUADRANT OF RIGHT FEMALE BREAST | Yes | |
| 9 | $191,648 | $9 | $191,639 | $0 | $191,639 | F84.0 | AUTISTIC DISORDER | Yes | |
| 10 | $187,415 | $175,444 | $11,971 | $0 | $11,971 | C50.411 | MALIG NEOPLM OF UPPER-OUTER QUADRANT OF RIGHT FEMALE BREAST | Yes | |
| 11 | $185,315 | $17,181 | $168,133 | $126,962 | $41,171 | G50.0 | TRIGEMINAL NEURALGIA | Yes | |
| 12 | $169,010 | $100,543 | $68,468 | $52,888 | $15,580 | E10.621 | TYPE 1 DIABETES MELLITUS WITH FOOT ULCER | Yes | |
| 13 | $165,170 | $15,179 | $149,991 | $0 | $149,991 | D80.6 | ANTIBODY DEFIC W NEAR-NORM IMMUNOGLOB OR W HYPERIMMUNOGLOB | Yes | |
| 14 | $164,733 | $3,475 | $161,258 | $143,122 | $18,136 | D50.0 | IRON DEFICIENCY ANEMIA SECONDARY TO BLOOD LOSS (CHRONIC) | Yes | |
| 15 | $159,979 | $1,738 | $158,241 | $149,020 | $9,221 | K29.40 | CHRONIC ATROPHIC GASTRITIS WITHOUT BLEEDING | Yes | |
| 16 | $155,899 | $254 | $155,646 | $122,802 | $32,844 | A41.9 | SEPSIS, UNSPECIFIED ORGANISM | Yes | |
| 17 | $151,817 | $0 | $151,817 | $151,210 | $608 | Z38.00 | SINGLE LIVEBORN INFANT, DELIVERED VAGINALLY | Yes | |
| Total | $4,096,395 | $1,680,041 | $2,416,354 | $1,679,009 | $737,346 |
File details come from the government source that posted it. Updated .