PRIYA SMITH
Dependent on policy B10M000068
Claims
2
Attributed to this person
Charged
614.00
Total submitted
Denied
447.00
2 denied claims
Patient responsibility
108.55
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 | PRIYA SMITH |
| Role on the policy | Dependent · relationship 01 |
| Policy | B10M000068 |
| Date of birth | 12 Mar 2000 |
| Plan | BRONZE EPO |
| Covered from | 6 May 2024 |
| Covered to | 4 Dec 2024 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 96 · Other | 1 | 108.55 |
| Total | 108.55 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000275 | 23 Jan 2025 | 447.00 | CASCADE CARE | CARC 27 · ELIGIBILITY | 447.00 |
| CLM0000274 | 28 Aug 2024 | 167.00 | CASCADE CARE | CARC 96 · NON_COVERED | 0.00 |