TOMAS USMAN
Subscriber on policy B02M000624
Claims
2
Attributed to this person
Charged
1,443.00
Total submitted
Denied
0.00
1 denied claims
Patient responsibility
515.45
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 USMAN |
| Role on the policy | Subscriber |
| Policy | B02M000624 |
| Date of birth | 26 May 1984 |
| Plan | SILVER HMO |
| Covered from | 4 Mar 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 50 · Other | 1 | 515.45 |
| Total | 515.45 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002622 | 19 May 2025 | 650.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0002623 | 5 Jan 2025 | 793.00 | NORTHSTAR MUTUAL | CARC 50 · MEDICAL_NECESSITY | 0.00 |