LEILA DIAZ
Dependent on policy B09M000724
Claims
3
Attributed to this person
Charged
2,104.00
Total submitted
Denied
752.00
1 denied claims
Patient responsibility
227.00
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 | LEILA DIAZ |
| Role on the policy | Dependent · relationship 01 |
| Policy | B09M000724 |
| Date of birth | 12 Feb 2003 |
| Plan | BRONZE EPO |
| Covered from | 24 Dec 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 1 · Deductible | 1 | 130.20 |
| CARC 2 · Coinsurance | 1 | 96.80 |
| Total | 227.00 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0003068 | 11 Apr 2025 | 484.00 | CASCADE CARE | Not denied | — |
| CLM0003066 | 3 Jan 2025 | 868.00 | CASCADE CARE | Not denied | — |
| CLM0003067 | 5 Dec 2024 | 752.00 | CASCADE CARE | CARC 26 · ELIGIBILITY | 752.00 |