GRACE USMAN
Dependent on policy B07M000208
Claims
1
Attributed to this person
Charged
314.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
62.80
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 | GRACE USMAN |
| Role on the policy | Dependent · relationship 19 |
| Policy | B07M000208 |
| Date of birth | 2 Dec 1993 |
| Plan | SILVER HMO |
| Covered from | 23 May 2024 |
| Covered to | 11 Jan 2025 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 62.80 |
| Total | 62.80 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000876 | 13 Jan 2025 | 314.00 | NORTHSTAR MUTUAL | Not denied | — |