Worker's Compensation Medical Management Service

CITY OF AUSTIN
EXHIBIT E - LOSS RUN REPORT
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z AA AB AC AD AE AF AG AH AI
WC Claim
Type as WC Claim
Claimant Full Date Claim Date Claim of Query Type - Examiner Examiner Examiner
Client Account Unit Formatted Name (Last Then Date of Reported Reported Date Claim Date Claim Date Claim Claim State Of State Of Line Line Coverage As Of Financial Claim Event Office Supervisor's Correspondence Date in Date Of Attorney Settlement Settlement Method of
1 Client# Name As of Date Name Name File NumberFirst) Loss to Client to TPA Opened Closed Reopened Status JurisdictionLoss Type Code Description Coverage CDoadtee Definition Subtype Substatus Loss Description Description Name Full Name Name Litigation SLtaittiugast(iYoens/NReop)resentation Type Date Settlement
Unknown work
related injury
0000 - as I could not
CITY OF read the
CITY OF 0000 - CITY AUSTIN documents
AUSTIN OF AUSTIN TRANSF Unknown work related injury as provided from
TRANSFERR TRANSFERRED ERRED Workers I could not read the documents the Urgent AUSTIN,
2 A000 ED CLAIMS 9/30/2023CLAIMS CLAIMS 99999Romeo, Juliet 3/31/2022 3/31/2022 4/22/2022 4/25/2022 10/4/2022 C TX TX WC WC Compensation WC MO MO Denied provided from the clinic. TX Mik Stevens Molly Boot No 0
0000 -
CITY OF
CITY OF 0000 - CITY AUSTIN
AUSTIN OF AUSTIN TRANSF
TRANSFERR TRANSFERRED ERRED Workers Medical bill received only - AUSTIN,
3 A000 ED CLAIMS 9/30/2023CLAIMS CLAIMS 88888Blacky, Joey 3/18/2022 5/3/2022 5/3/2022 5/3/2022 5/16/2022 C TX TX WC WC Compensation WC MO MO Denied manual entry Unknown TX Mik Stevens Tevi White No 0
Motor Vehicle,
CITY OF 0000 - CITY 0000- NOC All Other
AUSTIN OF AUSTIN TRANSF Motor Vehicle, NOC All Other (Specific)
TRANSFERR TRANSFERRED ERRED Workers (Specific) Injuries, NOC Whole Injuries, NOC AUSTIN,
4 A000 ED CLAIMS 9/30/2023CLAIMS CLAIMS 77777Audit, Medical 8/1/1989 8/1/1989 8/1/1989 8/1/1989 5/4/1994 C TX TX WC WC Compensation WC IN MO Accepted Body Whole Body TX Mik Stevens Tevi White Yes 0
Rt Little Finger
Abrasioniw Fell
From The
Dividing Wall
While Crossing
0001- Rt Little Finger Abrasioniw Fell Over It.
AUSTIN 0011 - AUSTIN PROFES Workers From The Dividing Wall While Seperates The AUSTIN,
5 A011 ENERGY 9/30/2023ENERGY SIONAL 66666Wobegone, Mike 4/26/2012 5/7/2012 5/7/2012 5/7/2012 I TX TX WC WC Compensation WC IO IO Pending Crossing Over It. Two TX Mik Stevens Deb Woodbe No 0
Rt Knee
Strainiw Was In
Pole Climbing
School And
While On The
0001- Rt Knee Strainiw Was In Pole Pole His SAN
AUSTIN 0011 - AUSTIN PROFES Workers Climbing School And While On Repositioned ANTONIO,
6 A011 ENERGY 9/30/2023ENERGY SIONAL 55555Winkers, Kevin 5/24/2012 5/30/2012 5/30/2012 5/30/2012 I TX TX WC WC Compensation WC IO IO Pending The Pole His Repositio His TX Mik Stevens Deb Woodbe No 0
IW was walking
and stepped
on a rock. The
rock rolled
causing him to
fall, hitting the
0001- IW was walking and stepped on ground on his SAN
AUSTIN 0011 - AUSTIN PROFES Workers a rock. The rock rolled causing right knee and ANTONIO,
7 A011 ENERGY 9/30/2023ENERGY SIONAL 44444Scott, Betty 3/4/2016 3/7/2016 3/8/2016 3/8/2016 I TX TX WC WC Compensation WC IO IO Pending him to fall, hitt hands TX Mik Stevens Deb Woodbe No 0
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AJ AK AL AM AN AO AP AQ AR AS AT AU AV AW AX AY AZ BA BB BC BD BE BF BG BH BI BJ BK BL BM BN BO BP BQ BR BS BT
Claim Claim Claim Claim Claim
Subrogation Cause Target/Part Last Days Claim Claim Claim Claim Future Future Future Future Claim Claim Incurred Claim Claim Claim Claim Claim Policy - Plan - Policy - Policy -
Status Description of Body Payment Since Last Paid - Paid - Paid - Paid - Reserve - Reserve - Reserve - Reserve - Incurred - Incurred - Incurred - Recovery - Recovery - Recovery Recovery Policy Carrier Inception Expiration Plan Structure Level Structure Level Structure Level Structure Level Structure Level Client Account Unit
1 (Yes/No) (Interaction) Result/Nature DDeescsrcirpiptitoionn Date Payment Ind/Loss Medical Expense Total Ind/Loss Medical Expense Total Ind/Loss - MedicalExpense Total Ind/Loss Expense - Medical- Total Number Name Date Date Number Name 01 Name 02 Name 03 Name 04 Name 05 Client Name Number Number Number
0000 - CITY OF 0000 - CITY OF 0000 - CITY OF 0000 - CITY OF
AUSTIN AUSTIN AUSTIN AUSTIN
Other Injury Multiple TRANSFERRED TRANSFERRED TRANSFERRED TRANSFERRED
2 N NEC All Other (SpecifiBco)dInyj uPraiertss,NOC 44806 393 0 0 9.45 9.45 0 0 0 0 0 0 9.45 9.45 0 0 0 0WC2022 44470 44834 1City of Austin CLAIMS CLAIMS CLAIMS CLAIMS City of Austin 7830783000011
Low Back
Area (Incl. 0000 - CITY OF 0000 - CITY OF 0000 - CITY OF 0000 - CITY OF
Lumbar & AUSTIN AUSTIN AUSTIN AUSTIN
Other Injury Lumbo- TRANSFERRED TRANSFERRED TRANSFERRED TRANSFERRED
3 N NEC No Physical InjurSyacral) 44694 505 0 0 9.45 9.45 0 0 0 0 0 0 9.45 9.45 0 0 0 0WC2022 44470 44834 1City of Austin CLAIMS CLAIMS CLAIMS CLAIMS City of Austin 7830783000011
0000 - CITY OF 0000 - CITY OF
AUSTIN AUSTIN 0000- 0000-
Motor TRANSFERRED TRANSFERRED TRANSFERRED TRANSFERRED
4 N Vehicle, NOC All Other (SpecifiWc)hInojlue rBieosd,yNOC 36571 8628 0 0 19502.18 19502.18 0 0 0 0 0 0 19502.18 19502.18 0 0 0 0WC1989 32417 32781 1City of Austin CLAIMS CLAIMS CLAIMS CLAIMS City of Austin 7830783000012
Fall/Slip
From a
Different 0011 - AUSTIN 1100-ELECTRIC 0001-
5 N Level Laceration Finger(s) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0WC2012 40817 41182 1City of Austin ENERGY 1110-ENERGY OPERATING PROFESSIONAL City of Austin 7830783000112
Strain or
Injury By, 0011 - AUSTIN 1100-ELECTRIC 0001-
6 N NOC Strain or Tear Knee 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0WC2012 40817 41182 1City of Austin ENERGY 1110-ENERGY OPERATING PROFESSIONAL City of Austin 7830783000112
0011 - AUSTIN 1100-ELECTRIC 0001-
7 N Twisting Strain or Tear Knee 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0WC2016 42278 42643 1City of Austin ENERGY 1110-ENERGY OPERATING PROFESSIONAL City of Austin 7830783000112
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