Exhibit_F_St_Cloud_Cigna_HCC_1021_to_0922.pdf
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- Solicitation number
- 2024-007
- Issued by
- Polk County, Florida
About this file
This document is a de-identified claims exceeding report from Cigna for the City of St. Cloud, covering health insurance claims from October 2021 through September 2022. The report details medical claims that exceeded $50,000, using a pooled stop-loss, retrospective experience-rated approach. The report includes comprehensive information about individual claims, categorized by member ID, status, gender, age band, and specific medical diagnosis codes.
The report reveals a total of 16 claims with a grand total of $1,791,149 in paid claims, with individual claim amounts ranging from $45,100 to $180,965. The claims cover a diverse range of medical conditions including malignant neoplasms, epilepsy, multiple sclerosis, osteomyelitis, heart disease, and various other diagnoses. The data is stratified by member type (employee, spouse, child) and includes details such as drug claims, paid claims, and total claimant costs. The document is marked as containing proprietary and confidential information, with a disclaimer from Cigna about the use of the report.
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Text version
Date: 1/25/2023
ADVICE Reporting System
This report contains proprietary and/or confidential information. Disclosure is strictly prohibited except to the extent required by law.
CITY OF ST. CLOUD
DE-IDENTIFIED CLAIMS EXCEEDING REPORT
October 2021 thru September 2022 Rating Type : POOLED STOP LOSS, RETROSPECTIVE EXPERIENCE RATED Claims Exceeding : $50,000.00 Reported Claims: InNet, OutNet, Drug Diagnosis is based on the largest medical claim amount Member Status is as of the most current month.
FUNDING TYPE RATING TYPE MEMBER ID MEMBER STATUS REL GENDER AGE BAND ICD CODE ICD DESCRIPTION ICD VERSION DRUG CLAIMS PAID CLAIMS CLAIMANT TOTAL
1 M 1 TERMINATED EE M 60-64 * UNSPECIFIED * $0 $45,100 $45,100
2 R 1 TERMINATED EE M 60-64 C3412 MALIGNANT NEOPLASM OF UPPER LOBE, LEFT BRONCHUS OR LUNG 10 $1,447 $173,046 $174,493 MEMBER ID Total $1,447 $218,146 $219,593
2 R 2 TERMINATED CH M 18-29 G40901 EPILEPSY, UNSP, NOT INTRACTABLE, WITH STATUS EPILEPTICUS 10 $1,011 $76,336 $77,347
2 R 3 TERMINATED EE F 30-39 N939 ABNORMAL UTERINE AND VAGINAL BLEEDING, UNSPECIFIED 10 $143 $68,158 $68,301
2 R 4 TERMINATED SP F 40-49 G35 MULTIPLE SCLEROSIS 10 $51,192 $5,924 $57,116
2 R 5 RETIREE EE M 60-64 T8451XA INFECT/INFLM REACTION DUE TO INTERNAL RIGHT HIP PROSTH, INIT 10 $42,364 $11,326 $53,690
2 R 6 ACTIVE EE F 60-64 M86171 OTHER ACUTE OSTEOMYELITIS, RIGHT ANKLE AND FOOT 10 $8,071 $55,096 $63,167
2 R 7 ACTIVE EE M 50-59 I209 ANGINA PECTORIS, UNSPECIFIED 10 $76,461 $2,891 $79,352
2 R 8 ACTIVE SP M 40-49 T8484XA PAIN DUE TO INTERNAL ORTHOPEDIC PROSTH DEV/GRFT, INIT 10 $496 $74,268 $74,763
2 R 9 TERMINATED EE M 30-39 K8050 CALCULUS OF BILE DUCT W/O CHOLANGITIS OR CHOLECYST W/O OBST 10 $6,767 $89,706 $96,473
2 R 10 TERMINATED EE M 50-59 A419 SEPSIS, UNSPECIFIED ORGANISM 10 $990 $137,717 $138,707
1 M 11 TERMINATED SP M 50-59 * UNSPECIFIED * $0 $180,965 $180,965
2 R 11 TERMINATED SP M 50-59 I2692 SADDLE EMBOLUS OF PULMONARY ARTERY W/O ACUTE COR PULMONALE 10 $51,747 $123,759 $175,505 MEMBER ID Total $51,747 $304,723 $356,470
2 R 12 TERMINATED EE M 50-59 I480 PAROXYSMAL ATRIAL FIBRILLATION 10 $5,154 $71,668 $76,823
2 R 13 ACTIVE EE M 60-64 I25119 ATHSCL HEART DISEASE OF NATIVE COR ART W UNSP ANG PCTRS 10 $472 $135,839 $136,310
2 R 14 ACTIVE EE M 50-59 K5732 DVTRCLI OF LG INT W/O PERFORATION OR ABSCESS W/O BLEEDING 10 $372 $112,527 $112,899
2 R 15 ACTIVE CH M 18-29 Q2739 ARTERIOVENOUS MALFORMATION, OTHER SITE 10 $2,900 $79,641 $82,541
2 R 16 TERMINATED EE M 60-64 G9340 ENCEPHALOPATHY, UNSPECIFIED 10 $236 $97,267 $97,504 2 R 16 TERMINATED EE M 65+ G3184 MILD COGNITIVE IMPAIRMENT OF UNCERTAIN OR UNKNOWN ETIOLOGY 10 $15 $76 $91 MEMBER ID Total $251 $97,344 $97,595
Grand Total $249,838 $1,541,311 $1,791,149
Cigna makes no warranty, express or implied, as to content and disclaims all liability arising directly or indirectly from use or reliance upon its contents by any third party even if Cigna has been advised of an intended use.
Claims Exceeding De-Identifi-1
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