IVAN SMITH
Dependent on policy B01M000706
Claims
3
Attributed to this person
Charged
1,093.00
Total submitted
Denied
69.00
1 denied claims
Patient responsibility
151.80
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 | IVAN SMITH |
| Role on the policy | Dependent · relationship 01 |
| Policy | B01M000706 |
| Date of birth | 5 Aug 1976 |
| Plan | GOLD PPO |
| Covered from | 19 Sep 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 151.80 |
| Total | 151.80 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0003148 | 27 Mar 2025 | 759.00 | CASCADE CARE | Not denied | — |
| CLM0003149 | 17 Feb 2025 | 69.00 | CASCADE CARE | CARC 16 · BILLING_ERROR | 69.00 |
| CLM0003147 | 3 Feb 2025 | 265.00 | CASCADE CARE | Not denied | — |