DAVID SMITH
Subscriber on policy B02M000281
Claims
2
Attributed to this person
Charged
1,123.00
Total submitted
Denied
205.97
1 denied claims
Patient responsibility
63.60
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 | DAVID SMITH |
| Role on the policy | Subscriber |
| Policy | B02M000281 |
| Date of birth | 2 Dec 1963 |
| Plan | SILVER HMO |
| Covered from | 25 Apr 2025 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 1 · Deductible | 1 | 63.60 |
| Total | 63.60 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001218 | 23 Oct 2025 | 699.00 | NORTHSTAR MUTUAL | CARC 27 · ELIGIBILITY | 205.97 |
| CLM0001219 | 7 Jun 2025 | 424.00 | NORTHSTAR MUTUAL | Not denied | — |