HENRY SMITH
Subscriber on policy B07M000504
Claims
1
Attributed to this person
Charged
457.00
Total submitted
Denied
0.00
1 denied claims
Patient responsibility
297.05
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 | HENRY SMITH |
| Role on the policy | Subscriber |
| Policy | B07M000504 |
| Date of birth | 6 Jul 2000 |
| Plan | PLATINUM PPO |
| Covered from | 18 Mar 2025 |
| Covered to | 7 Jul 2025 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 96 · Other | 1 | 297.05 |
| Total | 297.05 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002156 | 5 Jun 2025 | 457.00 | MERIDIAN HEALTH PLAN | CARC 96 · NON_COVERED | 0.00 |