GRACE VARGAS
Dependent on policy B07M000858
Claims
2
Attributed to this person
Charged
988.00
Total submitted
Denied
809.00
2 denied claims
Patient responsibility
116.35
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 | GRACE VARGAS |
| Role on the policy | Dependent · relationship 19 |
| Policy | B07M000858 |
| Date of birth | 22 Nov 2021 |
| Plan | BRONZE EPO |
| Covered from | 13 Apr 2024 |
| Covered to | 30 Nov 2024 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 96 · Other | 1 | 116.35 |
| Total | 116.35 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0003540 | 14 Jan 2025 | 179.00 | NORTHSTAR MUTUAL | CARC 96 · NON_COVERED | 0.00 |
| CLM0003541 | 1 May 2024 | 809.00 | NORTHSTAR MUTUAL | CARC 50 · MEDICAL_NECESSITY | 809.00 |