LEILA EVANS
Subscriber on policy B08M000634
Claims
3
Attributed to this person
Charged
1,764.00
Total submitted
Denied
862.00
2 denied claims
Patient responsibility
544.70
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 | LEILA EVANS |
| Role on the policy | Subscriber |
| Policy | B08M000634 |
| Date of birth | 7 May 1951 |
| Plan | GOLD PPO |
| Covered from | 23 Jan 2024 |
| Covered to | 17 Jun 2024 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 96 · Other | 1 | 544.70 |
| Total | 544.70 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002881 | 6 Jul 2024 | 862.00 | NORTHSTAR MUTUAL | CARC 27 · ELIGIBILITY | 862.00 |
| CLM0002882 | 12 May 2024 | 64.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0002880 | 14 Apr 2024 | 838.00 | NORTHSTAR MUTUAL | CARC 96 · NON_COVERED | 0.00 |