ELENA USMAN
Dependent on policy B01M000666
Claims
2
Attributed to this person
Charged
1,030.00
Total submitted
Denied
0.00
1 denied claims
Patient responsibility
374.30
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 | ELENA USMAN |
| Role on the policy | Dependent · relationship 01 |
| Policy | B01M000666 |
| Date of birth | 12 Jun 1952 |
| Plan | SILVER HMO |
| Covered from | 8 Mar 2024 |
| Covered to | 1 Jun 2024 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 50 · Other | 1 | 243.10 |
| CARC 2 · Coinsurance | 1 | 131.20 |
| Total | 374.30 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002988 | 25 May 2024 | 656.00 | CASCADE CARE | Not denied | — |
| CLM0002989 | 16 Apr 2024 | 374.00 | CASCADE CARE | CARC 50 · MEDICAL_NECESSITY | 0.00 |