TOMAS SMITH
Dependent on policy B09M000158
Claims
3
Attributed to this person
Charged
457.00
Total submitted
Denied
288.00
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 | TOMAS SMITH |
| Role on the policy | Dependent · relationship 01 |
| Policy | B09M000158 |
| Date of birth | 29 Aug 1972 |
| Plan | PLATINUM PPO |
| Covered from | 7 Aug 2024 |
| Covered to | 15 Jan 2025 |
Patient responsibility reported on the 835
No patient responsibility reported on this person's remittances.
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000664 | 27 Jan 2025 | 160.00 | NORTHSTAR MUTUAL | CARC 27 · ELIGIBILITY | 160.00 |
| CLM0000662 | 26 Jan 2025 | 128.00 | NORTHSTAR MUTUAL | CARC 27 · ELIGIBILITY | 128.00 |
| CLM0000663 | 30 Aug 2024 | 169.00 | NORTHSTAR MUTUAL | Not denied | — |