HENRY SMITH
Dependent on policy B09M000799
Claims
2
Attributed to this person
Charged
1,227.00
Total submitted
Denied
0.00
1 denied claims
Patient responsibility
458.55
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 | HENRY SMITH |
| Role on the policy | Dependent · relationship 01 |
| Policy | B09M000799 |
| Date of birth | 28 Aug 1963 |
| Plan | BRONZE EPO |
| Covered from | 25 Feb 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 50 · Other | 1 | 356.85 |
| CARC 1 · Deductible | 1 | 101.70 |
| Total | 458.55 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0003392 | 15 Apr 2026 | 678.00 | CASCADE CARE | Not denied | — |
| CLM0003393 | 20 Oct 2024 | 549.00 | CASCADE CARE | CARC 50 · MEDICAL_NECESSITY | 0.00 |