TOMAS EVANS
Subscriber on policy B08M000002
Claims
2
Attributed to this person
Charged
1,022.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
141.20
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 EVANS |
| Role on the policy | Subscriber |
| Policy | B08M000002 |
| Date of birth | 17 Jan 1991 |
| Plan | BRONZE EPO |
| Covered from | 15 Dec 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 141.20 |
| Total | 141.20 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000017 | 26 May 2026 | 706.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0000018 | 2 Apr 2026 | 316.00 | NORTHSTAR MUTUAL | Not denied | — |