HENRY SMITH
Dependent on policy B09M000119
Claims
2
Attributed to this person
Charged
1,046.00
Total submitted
Denied
893.92
2 denied claims
Patient responsibility
0.00
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 | HENRY SMITH |
| Role on the policy | Dependent · relationship 19 |
| Policy | B09M000119 |
| Date of birth | 10 Jun 2010 |
| Plan | PLATINUM PPO |
| Covered from | 20 Jul 2024 |
| Covered to | 3 Oct 2024 |
Patient responsibility reported on the 835
No patient responsibility reported on this person's remittances.
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000495 | 30 Oct 2024 | 763.00 | NORTHSTAR MUTUAL | CARC 26 · ELIGIBILITY | 763.00 |
| CLM0000494 | 5 Sep 2024 | 283.00 | NORTHSTAR MUTUAL | CARC 197 · AUTHORIZATION | 130.92 |