DAVID DIAZ
Dependent on policy B08M000467
Claims
2
Attributed to this person
Charged
690.00
Total submitted
Denied
232.00
2 denied claims
Patient responsibility
297.70
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 | DAVID DIAZ |
| Role on the policy | Dependent · relationship 19 |
| Policy | B08M000467 |
| Date of birth | 29 Sep 2010 |
| Plan | GOLD PPO |
| Covered from | 22 Mar 2025 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 96 · Other | 1 | 297.70 |
| Total | 297.70 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002158 | 21 Apr 2026 | 458.00 | NORTHSTAR MUTUAL | CARC 96 · NON_COVERED | 0.00 |
| CLM0002157 | 12 Mar 2025 | 232.00 | NORTHSTAR MUTUAL | CARC 26 · ELIGIBILITY | 232.00 |