LEILA DIAZ
Subscriber on policy B08M000348
Claims
3
Attributed to this person
Charged
1,481.00
Total submitted
Denied
448.00
2 denied claims
Patient responsibility
448.50
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 | LEILA DIAZ |
| Role on the policy | Subscriber |
| Policy | B08M000348 |
| Date of birth | 24 Aug 1951 |
| Plan | BRONZE EPO |
| Covered from | 21 Jan 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 50 · Other | 1 | 448.50 |
| Total | 448.50 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001603 | 30 Aug 2024 | 690.00 | NORTHSTAR MUTUAL | CARC 50 · MEDICAL_NECESSITY | 0.00 |
| CLM0001605 | 12 Jul 2024 | 343.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0001604 | 16 Jan 2024 | 448.00 | NORTHSTAR MUTUAL | CARC 26 · ELIGIBILITY | 448.00 |