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Cover Company Name/Logo
Time Period
Demographics Demographics
| Enrollment- Employees | MALE | FEMALE | TOTAL |
| Single | | | |
| Family With Spouse | | | |
| Family Without Spouse | | | |
| TOTAL EMPLOYEES | 0 | 0 | 0 |
| Employees |
| Male/Female% |
| Average Age |
| Enrollment- Members |
| Male/Female% |
| Average Age |
Incurred 07/01/2025 - 03/31/2026; Paid 01/01/2026 - 03/31/2026
Claims Summary Claims Summary
| Average # Employees |
| Average # Members |
| Total Claim Dollars | Inpatient | Outpatient | Total | |
| Inpatient/Outpatient | | | | Employee |
| PEPM | | | | Spouse |
| PMPM | | | | Other Dependent |
| Number of Utilizers | | | | Total |
| Total Claim Numbers | | | | |
| Network/Non-network Claims | Network | Non-Network | Total |
| Number of Claims | | | |
| Percentage of Total Number | | | |
| Cost | | | |
| Percentage of Total Cost | | | |
| Catastrophic Claims (>$100K) |
| Number of Claims |
| Total Dollar Amount |
| Percentage of Total Spend |
| Evaluated/Closed/Active |
| Top 5 Categories |
High-Cost Claimants High Cost Claimants
| Prior | Current | % Change | |
| Number of HCC Claimants | | | | |
| Membership | | | | Hide Row |
| Percent of Membership | | | | |
| Total HCC Dollar Amount | |
| Total Net Pay (Plan Spend) | Hide Row |
| Percentage of Group's Total Spend | |
Top 20 High-Cost Claimants
Relationship Age Gender Inpatient Paid Outpatient Paid Professional Paid Total Plan Paid Leading Diagnosis Engaged with CM? Prior Period HCC?
| Current Period |
| Top 5 Conditions | |
Cost Detail Cost Detail
| Top 20 Categories (MDC) | Inpatient | Please provide list, sorted by $ |
| Outpatient | Please provide list, sorted by $ |
| Total Paid | |
Inpatient MDC Category Paid Outpatient MDC Category Paid
TOTAL $0 TOTAL $0
Total Total Paid
TOTAL $0
| FACTORS INFLUENCING HEALTH | $21,223,752.39 |
| MUSCULOSKELETAL AND CONNECTIVE TISSUE | $19,348,558.35 |
| CIRCULATORY SYSTEM | $14,443,161.54 |
| DIGESTIVE SYSTEM | $12,510,305.79 |
| NEOPLASMS | $11,988,218.64 |
| SYMPTOMS, SIGNS, AND ABNORMAL FINDINGS | $10,797,481.40 |
| NERVOUS SYSTEM | $9,379,680.79 |
| INJURY, POISONING AND EXTERNAL CAUSE OUTCOMES | $9,367,534.44 |
| ENDOCRINE, NUTRITIONAL AND METABOLIC | $9,096,275.07 |
| GENITOURINARY SYSTEM | $7,346,411.28 |
| RESPIRATORY SYSTEM | $5,783,494.77 |
| PERINATAL CONDITIONS | $4,535,606.09 |
| PREGNANCY AND CHILDBIRTH | $4,389,283.14 |
| INFECTIOUS AND PARASITIC | $3,676,977.45 |
| CONGENITAL ABNORMALITIES | $3,165,306.82 |
| BLOOD AND CERTAIN IMMUNE DISORDERS | $2,860,361.85 |
| SKIN AND SUBCUTANEOUS TISSUE | $1,728,388.85 |
| EYE AND ADNEXA | $1,418,733.74 |
| MENTAL AND BEHAVIORAL DISORDERS | $1,351,403.00 |
| EAR AND MASTOID PROCESS | $1,311,092.05 |
| CODES FOR SPECIAL PURPOSES INCLUDING COVID-19 | $144,351.36 |
| EXTERNAL CAUSES OF MORBIDITY (DISEASE) | -$375.05 |
$155,866,003.76
Utilization Detail Utilization Detail
| Top 20 Categories | Inpatient | Please provide list, sorted by # |
| Total Employees | Outpatient | Please provide list, sorted by # |
| Total Members | PEPM for each | Please provide on list |
| PMPM for each | Please provide on list |
Inpatient Inpatient Claimants PEPM PMPM Outpatient Outpatient Claimants PEPM PMPM
TOTAL 0 TOTAL 0
Total Total Claimants PEPM PMPM
TOTAL 0
Preventive Preventive Screenings
| | Preventive Screenings (HEDIS) | | | | |
| | | Current Period Eligibles | Current Period Receiving Care | Current Period % Adherence | Benchmark |
| % Adherence | Prior Period | | | | | |
| Eligibles | Prior Period Receiving Care | Prior Period | | | | |
% Adherence
| Annual seasonal flu vaccine |
| Annual well visit, women 20+ years |
| Annual well visit, men 20+ years |
| Breast Cancer Screening |
| Cervical cancer screening |
| Colorectal cancer screening |
| Well Child Exam Age 0 - 14 Months |
| Well Child Exam Age 15 - 30 Months |
| Well Child Exam Age 3 - 21 Years |
| Zoster Vaccine Age Greater than Age 50 |
| HEDIS measures are calculated on a calendar-year basis. |
| The current period includes members enrolled and claims incurred from {dates} |
| The prior period includes members enrolled and claims incurred from {dates} |
| | Preventive Screenings (Others) | | | | |
| | | Current Period Eligibles | Current Period Receiving Care | Current Period % Adherence | Benchmark |
| % Adherence | Prior Period | | | | | |
| Eligibles | Prior Period Receiving Care | Prior Period | | | | |
% Adherence
| Annual lipid test, women |
| Annual lipid test, men |
| Eye exam for age >= 55 years without risk factors |
| Eye exam for age 40-54 years without risk factors |
| Prostate Cancer Screening Age 50 -64 |
| Preventive screenings (others) are tracked continuously across the fiscal year to capture total utilizers. |
| Current period claims incurred and paid: {insert dates} |
| Prior period: {insert dates} |
Autism Autism Claims
| Claimants | Services | Visits | Procedures | Covered | Paid |
| Physical Therapy | | | | | | |
| Occupational Therapy | | | | | | |
| Speech Therapy | | | | | | |
Diabetes Diabetes Utilization
| Members With A1c Test This Quarter | | | Members Without A1c Test This Quarter | | | TOTAL - ALL DIABETICS | | |
| Prior | Current | % Change | Prior | Current | % Change | Prior | Current | % Change |
| Total Net paid for all Members | $132,704,462.26 | $0.00 | -100.0% | $132,704,462.26 | $0.00 | -100.0% | $132,704,462.26 | $0.00 | -100.0% |
| Net paid for Diabetics | | | | | | | | | |
| Net paid for Diabetics - Diabetes diagnosis | | | | | | | | | |
| Net paid for Diabetics - Other diagnosis | | | | | | | | | |
| Net paid for Non-Diabetics | | | | | | | | | |
| Total Members | | | | | | | | | |
| Total Claimants | | | | | | | | | |
| Claimants identified as Diabetics |
| Medical Net Paid PMPM for Diabetes |
| Diabetes diagnosis |
| Other diagnosis |
| Diabetics as a % of all claimants |
| Average Net Paid per Diabetic |
Costs for Diabetics as % of Total
| Prior | Current | % Change |
| Average Net Paid per Non-Diabetic | | | |
Hospital Data Hospital Data - Inpatient & Outpatient
| Total Employees |
| Total Members |
| Total Inpatient Payments | Days Per 1,000 |
| Total Inpatient Admits | ALOS |
| Total Inpatient Days | Avg Pd/Admit |
| Admissions Per 1,000 | |
| TOP 25 INPATIENT BY COST | | | | | |
| Hospital Name | City | State | Admits | Days | Paid Amount |
Total 0 0 $0
| TOP 25 INPATIENT BY ADMISSIONS | | | | | |
| Hospital Name | City | State | Admits | Days | Paid Amount |
Total 0 0 $0
| Total Outpatient Payments |
| Total Outpatient Claims |
| Average Paid Per Outpatient Claim |
| TOP 25 OUTPATIENT BY PAYMENT | | | | |
| Hospital Name | City | State | Claims | Paid |
Total 0 $0
| TOP 25 OUTPATIENT BY CLAIM COUNT | | | | |
| Hospital Name | City | State | Claims | Paid |
Total 0 $0
Provider Data Doctor Data
| Payments |
| Total Members |
| Total Claims |
| Claims Per 1,000 |
| Average Paid Per Claim |
| TOP 25 PROFESSIONAL PROVIDERS BY COST | | | | | |
| Provider Name | Provider City | State | Specialty | Claims | Paid |
Total 0 $0
| TOP 25 PROFESSIONAL PROVIDERS BY CLAIM COUNT | | | | | |
| Provider Name | Provider City | State | Specialty | Claims | Paid |
Total 0 $0
| TOP 25 PROFESSIONAL/ANCILLARY PROVIDERS BY COST | | | | | |
| Provider Name | Provider City | State | Specialty | Claims | Amount |
Total 0 $0
ER-UC-CC
| ER Visits- Outpatient Hospital Claims | |
| ER Visits | Total Members |
| Emergency Visits |
| Non Emergency Visits |
| Total Visits |
| Total Visits/1,000 |
| Emergency Paid |
| Non Emergency Paid |
| Total Paid |
| Average Paid Per Visit |
| Number Admitted |
| Urgent Care | |
| Total Visits |
| Visits/1,000 |
| Total Paid |
| Average Paid Per Visit |
| Convenience Clinics | |
| Total Visits |
| Visits/1,000 |
| Total Paid |
| Average Paid Per Visit |
Cost Sharing Cost Sharing
| Total Members | |
| TOTAL Allowed Amount | |
| Employee Total Costs | |
| Total Members with claims | EE-Only |
| Percent of Total Allowed Amount | YTD |
| Number and % Meeting Deductible | |
| Number and % Meeting Single Deductible | |
| Number and % Meeting Family Deductible | |
| Number and % Meeting OPM | |
| Number and % Meeting Single OPM | |
| Number and % Meeting Family OPM | |
| Number and % With No Claims | |
Subrogation Subrogation
| Injury Type | Sum of Total Lien Amount | Sum of Recovery Amount | Sum of Atty Fees | Sum of Subrogation Fees | Sum of Net Recovery |
| Animal | | | | | |
| Auto | | | | | |
| Pedestrian | | | | | |
| Slip/Fall | | | | | |
| Vendor Recovery | | | | | |
| Workers Compensation | | | | | |
| Other | | | | | |
| Grand Total | $0 | $0 | $0 | $0 | $0 |
Auto includes First Party, Third Party, and Motorcycle
Appeals & PGs Appeals
Member Appeal: A formal case opened by the Member appeals unit. These are adverse benefit determinations where a claim or services is denied, payment reduced or terminated. This would include appeals that come in from calls (rare), written and via the internet. This does not include complaints filed with the department of insurance, correspondence or calls handled by any other area in the Company. These include all level of appeals. Partial Appeals are classified as "Upheld" since it was not fully approved.
| Cases Received | Upheld | Overturned | % Overturned |
| First Level Internal Appeals | | | | |
Second Level Internal Appeals
ODI Contractual
| External Reviews (IRO) | | | |
| All Appeals | 0 | 0 | 0 |
Provider Appeal: Appeals include inpatient, outpatient and predeterminations; physician and hospital.
| Cases Received | Upheld | Overturned | % Overturned |
| Provider Appeals | | | | |
| First Level Internal Appeal: Mandatory level of appeal. |
| Second Level Internal Appeal: Voluntary level of appeal after First Level is exhausted. |
| ODI Contractual Appeal: Review for adverse benefit determinations based on contractual issues not involving medical judgment or medical information. |
| External Review (IRO): Review for adverse benefit determinations that involved a medical judgment or was based on medical information (medical necessity). |
ICD10 Chapters
ICD-10 CHAPTERS AND SAMPLE CONDITIONS
| The following Chapters are based upon the International Classification of Diseases – 10th Revision, which is published by the United States Government. |
| Each Chapter consists of a specific range of diagnosis codes. Examples of diseases/conditions are shown for each Chapter. |
| Chapter 1: Infectious and Parasitic Diseases [A00 – B99] [Diseases generally recognized as communicable or transmissible] | |
| - | Hepatitis |
| - | Measles |
| - | AIDS |
| - | Salmonella |
| Chapter 2: Neoplasms [C00 – D49] | |
| - | Malignant neoplasms (cancer) |
| - | Leukemia |
| - | Benign neoplasms (non-cancerous) |
| Chapter 3: Diseases of the Blood and Blood Forming Organs and Certain Disorders Involving the Immune System [D50 – D89] | |
| - | Nutritional Anemias (Iron Deficiency) |
| - | Hemorrhagic conditions |
| - | Coagulation defects (Hemophilia) |
| Chapter 4: Endocrine, Nutritional, and Metabolic Diseases [E00 – E89] | |
| - | Diabetes |
| - | Malnutrition |
| - | Obesity |
| - | Hypothyroidism |
| Chapter 5: Mental, Behavioral, and Neurodevelopmental Disorders [F01 – F99] | |
| - | Alcohol-related disorders |
| - | Schizophrenia |
| - | Bipolar Disorders |
| - | Sleep Disorders |
| - | Anxiety Disorders |
| Chapter 6: Diseases of the Nervous System [G00 – G99] | |
| - | Meningitis |
| - | Parkinson’s Disease |
| - | Alzheimer’s Disease |
| - | Multiple Sclerosis |
| - | Migraine |
| Chapter 7: Diseases of the Eye and Adnexa [H00 – H59] | |
| [Includes the visual structures of the eye including eyebrow, eyelids and lacrimal apparatus] | |
| - | Conjunctivitis |
| - | Cataracts |
| - | Glaucoma |
| - | Retinal Detachments |
| Chapter 8: Diseases of the Ear and Mastoid Process [H60 – H95] | |
| - | Ear infections |
| - | Perforation of ear drum |
| - | Vertigo [sense of balance] |
| Chapter 9: Diseases of the Circulatory System [I00 – I99] [Conditions related to the cardiovascular system] | |
| - | Hypertension |
| - | Heart attack |
| - | Blood Clot |
| - | Stroke |
| Chapter 10: Diseases of the Respiratory System [J00 – J99] | |
| - | Influenza |
| - | Asthma |
| - | Pneumonia |
| - | Emphysema |
| - | Bronchitis |
| Chapter 11: Diseases of the Digestive System [K00 – K95] | |
| [Includes disorders related to the organs and glands associated with the ingestion and digestion of food] | |
| - | Appendicitis |
| - | Ulcers |
| - | Hernia |
| - | Gallstones |
| Chapter 12: Diseases of the Skin and Subcutaneous Tissue [L00 – L99] | |
| - | Dermatitis |
| - | Hives |
| - | Acne |
| - | Rash |
| Chapter 13: Diseases of the Musculoskeletal and Connective Tissue [M00 – M99] | |
| - | Arthritis |
| - | Gout |
| - | Joint or Bone disorders |
| - | Osteoporosis |
| - | Fractures |
| Chapter 14: Diseases of the Genitourinary System [N00 – N99] [Conditions related to reproduction and urination] | |
| - | Kidney Disease |
| - | Endometriosis |
| - | Infertility |
| - | Menopause |
| Chapter 15: Pregnancy, Childbirth and the Puerperium [O00 – O9A] | |
| [Puerperium is defined as the period of about six weeks after childbirth during which the mother's reproductive organs return to their original non-pregnant condition.] | |
| - | Miscarriage |
| - | High Risk Pregnancy |
| - | Preterm Labor |
| - | Multiple Gestation |
| Chapter 16: Conditions Originating in the Perinatal Period [P00 – P96] | |
| [Conditions that have their origin in the fetal or perinatal period - before birth through the first 28 days after birth] | |
| - | Perinatal Infection |
| - | Neonatal Aspiration |
| - | Low birth Weight |
| Chapter 17: Congenital Malformations, Deformations, and Chromosomal Abnormalities [Q00 – Q99] [Abnormalities or irregularities at birth] | |
| - | Cleft Palate |
| - | Spina Bifida |
| - | Stillbirth |
| Chapter 18: Symptoms, Signs and Abnormal Clinical and Laboratory Findings – Not Elsewhere Classified [R00 – R99] | |
| [Includes vague symptoms or conditions for which no diagnosis can be made] | |
| - | Nausea and vomiting |
| - | Pain |
| - | Headache |
| - | Enlarged lymph nodes |
| Chapter 19: Injury, Poisoning, and Certain Other Consequences of External Causes [S00 – T88] | |
| [Conditions include toxic effects from external causes (e.g. frostbite) or complications of surgical and/or medical care] | |
| - | Sprains, fractures, and open wounds |
| - | Joint dislocations |
| - | Carbon Monoxide Poisoning |
| - | Toxicity from contact with venomous animals and plants |
| Chapter 20: External Causes of Morbidity [V00 – Y99] | |
| - | Assault |
| - | Bicycle, motorcycle and automobile accident |
| - | Exposure to smoke, fire or flames |
| - | Slipping, tripping, stumbling or falls |
| Chapter 21: Factors Influencing Health Status and Contact with Health Services [Z00 – Z99] | |
| - | Examinations for persons with potential health hazards related to contact or exposure to communicable diseases |
| - | Encounter for medical observation to rule out suspected diseases or conditions |
| - | Organ or tissue donors |
| - | Prophylactic or elective surgery |