LEILA WILSON
Dependent on policy B07M000651
Claims
2
Attributed to this person
Charged
1,331.00
Total submitted
Denied
632.00
2 denied claims
Patient responsibility
454.35
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 | LEILA WILSON |
| Role on the policy | Dependent · relationship 01 |
| Policy | B07M000651 |
| Date of birth | 9 Dec 2004 |
| Plan | GOLD PPO |
| Covered from | 31 Mar 2025 |
| Covered to | 22 Dec 2025 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 50 · Other | 1 | 454.35 |
| Total | 454.35 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002711 | 12 Jul 2025 | 699.00 | NORTHSTAR MUTUAL | CARC 50 · MEDICAL_NECESSITY | 0.00 |
| CLM0002712 | 20 Mar 2025 | 632.00 | NORTHSTAR MUTUAL | CARC 26 · ELIGIBILITY | 632.00 |