DAVID EVANS
Subscriber on policy B02M000540
Claims
2
Attributed to this person
Charged
1,114.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
178.00
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 EVANS |
| Role on the policy | Subscriber |
| Policy | B02M000540 |
| Date of birth | 11 Jun 1982 |
| Plan | SILVER HMO |
| Covered from | 13 Sep 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 178.00 |
| Total | 178.00 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002281 | 12 Apr 2025 | 224.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0002280 | 18 Feb 2025 | 890.00 | NORTHSTAR MUTUAL | Not denied | — |