TOMAS DIAZ
Subscriber on policy B07M000728
Claims
3
Attributed to this person
Charged
1,536.00
Total submitted
Denied
737.00
2 denied claims
Patient responsibility
312.00
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 DIAZ |
| Role on the policy | Subscriber |
| Policy | B07M000728 |
| Date of birth | 2 May 1987 |
| Plan | SILVER HMO |
| Covered from | 6 Jun 2024 |
| Covered to | 5 Jan 2025 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 96 · Other | 1 | 312.00 |
| Total | 312.00 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0003011 | 18 Jan 2025 | 737.00 | CASCADE CARE | CARC 27 · ELIGIBILITY | 737.00 |
| CLM0003010 | 3 Oct 2024 | 319.00 | CASCADE CARE | Not denied | — |
| CLM0003012 | 4 Sep 2024 | 480.00 | CASCADE CARE | CARC 96 · NON_COVERED | 0.00 |