TOMAS ANDERSON
Dependent on policy B02M000094
Claims
1
Attributed to this person
Charged
513.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
102.60
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 | TOMAS ANDERSON |
| Role on the policy | Dependent · relationship 01 |
| Policy | B02M000094 |
| Date of birth | 15 Feb 1975 |
| Plan | SILVER HMO |
| Covered from | 14 Jan 2024 |
| Covered to | 18 Jul 2024 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 102.60 |
| Total | 102.60 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000430 | 21 Jun 2024 | 513.00 | NORTHSTAR MUTUAL | Not denied | — |