GRACE SMITH
Dependent on policy B08M000102
Claims
3
Attributed to this person
Charged
1,311.00
Total submitted
Denied
142.66
1 denied claims
Patient responsibility
74.70
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 SMITH |
| Role on the policy | Dependent · relationship 19 |
| Policy | B08M000102 |
| Date of birth | 4 Mar 2010 |
| Plan | SILVER HMO |
| Covered from | 24 Feb 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 1 · Deductible | 1 | 74.70 |
| Total | 74.70 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000453 | 16 Jul 2024 | 102.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0000452 | 2 Apr 2024 | 711.00 | NORTHSTAR MUTUAL | CARC 18 · DUPLICATE | 142.66 |
| CLM0000454 | 10 Feb 2024 | 498.00 | NORTHSTAR MUTUAL | Not denied | — |