WENDY EVANS
Dependent on policy B02M000386
Claims
2
Attributed to this person
Charged
1,441.00
Total submitted
Denied
634.00
2 denied claims
Patient responsibility
524.55
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 | WENDY EVANS |
| Role on the policy | Dependent · relationship 01 |
| Policy | B02M000386 |
| Date of birth | 28 Aug 2004 |
| Plan | PLATINUM PPO |
| Covered from | 24 Feb 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 50 · Other | 1 | 524.55 |
| Total | 524.55 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001640 | 31 Jan 2026 | 634.00 | NORTHSTAR MUTUAL | CARC 50 · MEDICAL_NECESSITY | 634.00 |
| CLM0001641 | 14 Jul 2024 | 807.00 | NORTHSTAR MUTUAL | CARC 50 · MEDICAL_NECESSITY | 0.00 |