PRIYA EVANS
Dependent on policy B02M000319
Claims
2
Attributed to this person
Charged
1,416.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
110.20
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 EVANS |
| Role on the policy | Dependent · relationship 19 |
| Policy | B02M000319 |
| Date of birth | 12 Apr 2005 |
| Plan | GOLD PPO |
| Covered from | 14 Feb 2024 |
| Covered to | 12 Oct 2024 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 110.20 |
| Total | 110.20 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001360 | 3 Nov 2024 | 551.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0001359 | 27 Apr 2024 | 865.00 | NORTHSTAR MUTUAL | Not denied | — |