CARLA SMITH
Dependent on policy B08M000193
Claims
3
Attributed to this person
Charged
1,701.00
Total submitted
Denied
253.00
1 denied claims
Patient responsibility
261.25
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 | CARLA SMITH |
| Role on the policy | Dependent · relationship 19 |
| Policy | B08M000193 |
| Date of birth | 28 Apr 1997 |
| Plan | SILVER HMO |
| Covered from | 11 Feb 2024 |
| Covered to | 6 Jul 2024 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 176.20 |
| CARC 1 · Deductible | 1 | 85.05 |
| Total | 261.25 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000860 | 28 Jun 2024 | 881.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0000859 | 8 Apr 2024 | 567.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0000861 | 3 Mar 2024 | 253.00 | NORTHSTAR MUTUAL | CARC 109 · COB | 253.00 |