GRACE DIAZ
Dependent on policy B02M000728
Claims
2
Attributed to this person
Charged
930.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
25.00
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 | GRACE DIAZ |
| Role on the policy | Dependent · relationship 01 |
| Policy | B02M000728 |
| Date of birth | 15 Jan 2000 |
| Plan | BRONZE EPO |
| Covered from | 13 Dec 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 3 · Copay | 1 | 25.00 |
| Total | 25.00 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0003050 | 28 Feb 2026 | 598.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0003051 | 17 Sep 2025 | 332.00 | NORTHSTAR MUTUAL | Not denied | — |