GRACE SMITH
Subscriber on policy B09M000260
Claims
2
Attributed to this person
Charged
890.00
Total submitted
Denied
106.37
1 denied claims
Patient responsibility
79.20
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 | GRACE SMITH |
| Role on the policy | Subscriber |
| Policy | B09M000260 |
| Date of birth | 2 Aug 1999 |
| Plan | BRONZE EPO |
| Covered from | 25 Sep 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 79.20 |
| Total | 79.20 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001063 | 5 Mar 2026 | 396.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0001062 | 28 Aug 2025 | 494.00 | NORTHSTAR MUTUAL | CARC 27 · ELIGIBILITY | 106.37 |