GRACE EVANS
Dependent on policy B10M000773
Claims
1
Attributed to this person
Charged
706.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
105.90
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 | Dependent · relationship 01 |
| Policy | B10M000773 |
| Date of birth | 19 Nov 1966 |
| Plan | BRONZE EPO |
| Covered from | 15 Oct 2024 |
| Covered to | 23 Jul 2025 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 1 · Deductible | 1 | 105.90 |
| Total | 105.90 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0003235 | 18 Feb 2025 | 706.00 | MERIDIAN HEALTH PLAN | Not denied | — |