DAVID SMITH
Subscriber on policy B10M000569
Claims
1
Attributed to this person
Charged
842.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
168.40
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 | DAVID SMITH |
| Role on the policy | Subscriber |
| Policy | B10M000569 |
| Date of birth | 15 Mar 1985 |
| Plan | PLATINUM PPO |
| Covered from | 12 Mar 2025 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 168.40 |
| Total | 168.40 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002357 | 30 Aug 2025 | 842.00 | NORTHSTAR MUTUAL | Not denied | — |