HENRY SMITH
Dependent on policy B07M000279
Claims
1
Attributed to this person
Charged
632.00
Total submitted
Denied
0.00
1 denied claims
Patient responsibility
410.80
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 | HENRY SMITH |
| Role on the policy | Dependent · relationship 01 |
| Policy | B07M000279 |
| Date of birth | 2 Dec 1998 |
| Plan | SILVER HMO |
| Covered from | 7 Apr 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 50 · Other | 1 | 410.80 |
| Total | 410.80 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001207 | 3 Apr 2024 | 632.00 | NORTHSTAR MUTUAL | CARC 50 · MEDICAL_NECESSITY | 0.00 |