GRACE QUINN
Dependent on policy B08M000161
Claims
2
Attributed to this person
Charged
284.00
Total submitted
Denied
0.00
1 denied claims
Patient responsibility
102.80
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 QUINN |
| Role on the policy | Dependent · relationship 19 |
| Policy | B08M000161 |
| Date of birth | 7 Apr 2008 |
| Plan | BRONZE EPO |
| Covered from | 19 Jun 2024 |
| Covered to | 2 Oct 2024 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 50 · Other | 1 | 72.80 |
| CARC 3 · Copay | 1 | 30.00 |
| Total | 102.80 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000741 | 9 Nov 2024 | 112.00 | NORTHSTAR MUTUAL | CARC 50 · MEDICAL_NECESSITY | 0.00 |
| CLM0000742 | 30 Jun 2024 | 172.00 | NORTHSTAR MUTUAL | Not denied | — |