SOFIA GARCIA
Dependent on policy B01M000760
Claims
3
Attributed to this person
Charged
760.00
Total submitted
Denied
202.80
1 denied claims
Patient responsibility
25.95
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 | SOFIA GARCIA |
| Role on the policy | Dependent · relationship 01 |
| Policy | B01M000760 |
| Date of birth | 1 Jun 1996 |
| Plan | GOLD PPO |
| Covered from | 3 May 2024 |
| Covered to | 5 Aug 2024 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 1 · Deductible | 1 | 25.95 |
| Total | 25.95 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0003389 | 19 Sep 2024 | 173.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0003387 | 16 Jul 2024 | 149.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0003388 | 5 Jun 2024 | 438.00 | NORTHSTAR MUTUAL | CARC 11 · CODING | 202.80 |