RAVI SMITH
Dependent on policy B09M000113
Claims
1
Attributed to this person
Charged
805.00
Total submitted
Denied
0.00
1 denied claims
Patient responsibility
523.25
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 | RAVI SMITH |
| Role on the policy | Dependent · relationship 01 |
| Policy | B09M000113 |
| Date of birth | 25 Jun 1974 |
| Plan | SILVER HMO |
| Covered from | 30 Nov 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 96 · Other | 1 | 523.25 |
| Total | 523.25 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000464 | 15 Apr 2025 | 805.00 | NORTHSTAR MUTUAL | CARC 96 · NON_COVERED | 0.00 |