DAVID DIAZ
Subscriber on policy B09M000717
Claims
2
Attributed to this person
Charged
513.00
Total submitted
Denied
0.00
1 denied claims
Patient responsibility
42.25
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 | DAVID DIAZ |
| Role on the policy | Subscriber |
| Policy | B09M000717 |
| Date of birth | 24 Oct 1982 |
| Plan | SILVER HMO |
| Covered from | 2 Jan 2025 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 96 · Other | 1 | 42.25 |
| Total | 42.25 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0003041 | 17 May 2026 | 448.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0003042 | 9 May 2025 | 65.00 | NORTHSTAR MUTUAL | CARC 96 · NON_COVERED | 0.00 |