LEILA DIAZ
Dependent on policy B10M000408
Claims
1
Attributed to this person
Charged
477.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
95.40
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 19 |
| Policy | B10M000408 |
| Date of birth | 4 Jun 2013 |
| Plan | GOLD PPO |
| Covered from | 16 Nov 2024 |
| Covered to | 28 Apr 2025 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 95.40 |
| Total | 95.40 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001698 | 23 Nov 2024 | 477.00 | NORTHSTAR MUTUAL | Not denied | — |