UMA SMITH
Dependent on policy B09M000119
Claims
3
Attributed to this person
Charged
1,184.00
Total submitted
Denied
361.00
2 denied claims
Patient responsibility
479.05
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 | UMA SMITH |
| Role on the policy | Dependent · relationship 19 |
| Policy | B09M000119 |
| Date of birth | 7 Mar 2023 |
| Plan | PLATINUM PPO |
| Covered from | 20 Jul 2024 |
| Covered to | 3 Oct 2024 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 50 · Other | 1 | 479.05 |
| Total | 479.05 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000492 | 15 Nov 2024 | 361.00 | NORTHSTAR MUTUAL | CARC 27 · ELIGIBILITY | 361.00 |
| CLM0000491 | 16 Sep 2024 | 86.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0000493 | 16 Sep 2024 | 737.00 | NORTHSTAR MUTUAL | CARC 50 · MEDICAL_NECESSITY | 0.00 |