TOMAS EVANS
Dependent on policy B06M000307
Claims
2
Attributed to this person
Charged
717.00
Total submitted
Denied
212.21
1 denied claims
Patient responsibility
22.00
Reported on the 835
Patient responsibility is the amount reported on the 835 as assigned to the patient — deductible, coinsurance or copay. It is not proof that the provider billed the member, that the member owes it, or that it was collected, and it is kept separate from denied amounts throughout.
Who this is
| Field | Value |
|---|---|
| Name | TOMAS EVANS |
| Role on the policy | Dependent · relationship 01 |
| Policy | B06M000307 |
| Date of birth | 29 Dec 1960 |
| Plan | SILVER HMO |
| Covered from | 11 Nov 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 22.00 |
| Total | 22.00 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001405 | 10 Mar 2026 | 110.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0001406 | 6 Mar 2025 | 607.00 | NORTHSTAR MUTUAL | CARC 96 · NON_COVERED | 212.21 |