TOMAS SMITH
Dependent on policy B01M000306
Claims
2
Attributed to this person
Charged
756.00
Total submitted
Denied
572.00
1 denied claims
Patient responsibility
27.60
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 | TOMAS SMITH |
| Role on the policy | Dependent · relationship 19 |
| Policy | B01M000306 |
| Date of birth | 9 Feb 2019 |
| Plan | PLATINUM PPO |
| Covered from | 30 Oct 2024 |
| Covered to | 7 Aug 2025 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 1 · Deductible | 1 | 27.60 |
| Total | 27.60 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001349 | 13 Apr 2025 | 184.00 | CASCADE CARE | Not denied | — |
| CLM0001350 | 23 Dec 2024 | 572.00 | CASCADE CARE | CARC 27 · ELIGIBILITY | 572.00 |