GRACE SMITH
Dependent on policy B08M000462
Claims
2
Attributed to this person
Charged
1,039.00
Total submitted
Denied
0.00
1 denied claims
Patient responsibility
592.85
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 01 |
| Policy | B08M000462 |
| Date of birth | 11 Dec 1972 |
| Plan | GOLD PPO |
| Covered from | 13 Feb 2025 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 50 · Other | 1 | 568.10 |
| CARC 1 · Deductible | 1 | 24.75 |
| Total | 592.85 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002128 | 11 Nov 2025 | 165.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0002127 | 18 May 2025 | 874.00 | NORTHSTAR MUTUAL | CARC 50 · MEDICAL_NECESSITY | 0.00 |