TOMAS DIAZ
Dependent on policy B09M000420
Claims
1
Attributed to this person
Charged
534.00
Total submitted
Denied
0.00
1 denied claims
Patient responsibility
347.10
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 DIAZ |
| Role on the policy | Dependent · relationship 01 |
| Policy | B09M000420 |
| Date of birth | 21 Apr 1987 |
| Plan | GOLD PPO |
| Covered from | 20 Dec 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 50 · Other | 1 | 347.10 |
| Total | 347.10 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001747 | 25 Feb 2025 | 534.00 | NORTHSTAR MUTUAL | CARC 50 · MEDICAL_NECESSITY | 0.00 |