GRACE EVANS
Subscriber on policy B09M000293
Claims
2
Attributed to this person
Charged
858.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
111.60
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 EVANS |
| Role on the policy | Subscriber |
| Policy | B09M000293 |
| Date of birth | 6 Apr 1987 |
| Plan | GOLD PPO |
| Covered from | 2 May 2024 |
| Covered to | 12 Aug 2024 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 1 · Deductible | 1 | 111.60 |
| Total | 111.60 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001204 | 17 Sep 2024 | 114.00 | CASCADE CARE | Not denied | — |
| CLM0001203 | 4 Aug 2024 | 744.00 | CASCADE CARE | Not denied | — |