TOMAS CHEN
Dependent on policy B01M000771
Claims
3
Attributed to this person
Charged
1,644.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
163.30
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 CHEN |
| Role on the policy | Dependent · relationship 19 |
| Policy | B01M000771 |
| Date of birth | 21 Nov 2016 |
| Plan | GOLD PPO |
| Covered from | 14 Jun 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 83.80 |
| CARC 1 · Deductible | 1 | 79.50 |
| Total | 163.30 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0003428 | 13 Oct 2025 | 695.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0003429 | 10 Sep 2025 | 419.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0003430 | 6 Feb 2025 | 530.00 | NORTHSTAR MUTUAL | Not denied | — |