Exhibit_F_St_Cloud_Cigna_HCC_1022_to_1222.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 medical claims from October through December 2022. The report details claims exceeding $50,000.00 under a Pooled Stop Loss, Retrospective Experience Rated funding type, with claims reported for in-network, out-of-network, and drug expenses.
The report includes three specific claims entries, with total drug claims of $1,026 and paid claims of $229,885, resulting in a grand total of $230,911. The claims involve terminated and active members, primarily in the 50-59 age band, with diagnoses including sepsis, acute respiratory failure, and paroxysmal atrial fibrillation. The document is dated 1/25/2023 and contains a disclaimer from Cigna about the proprietary and confidential nature of the information, with strict prohibitions on disclosure except as required by law.
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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 2022 thru December 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
2 R 1 TERMINATED SP F 60-64 A419 SEPSIS, UNSPECIFIED ORGANISM 10 $0 $78,170 $78,170
1 M 2 TERMINATED SP M 50-59 * UNSPECIFIED * $0 $505 $505
2 R 2 TERMINATED SP M 50-59 J9601 ACUTE RESPIRATORY FAILURE WITH HYPOXIA 10 $0 $98,021 $98,021 MEMBER ID Total $0 $98,526 $98,526
2 R 3 ACTIVE EE M 50-59 I480 PAROXYSMAL ATRIAL FIBRILLATION 10 $1,026 $53,188 $54,214
Grand Total $1,026 $229,885 $230,911
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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