TOMAS EVANS
Dependent on policy B03M000138
Claims
3
Attributed to this person
Charged
805.00
Total submitted
Denied
144.00
2 denied claims
Patient responsibility
313.30
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 EVANS |
| Role on the policy | Dependent · relationship 19 |
| Policy | B03M000138 |
| Date of birth | 31 Dec 2012 |
| Plan | BRONZE EPO |
| Covered from | 26 Sep 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 96 · Other | 1 | 313.30 |
| Total | 313.30 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000563 | 11 Aug 2025 | 179.00 | MERIDIAN HEALTH PLAN | Not denied | — |
| CLM0000561 | 5 Jul 2025 | 144.00 | MERIDIAN HEALTH PLAN | CARC 29 · TIMELY_FILING | 144.00 |
| CLM0000562 | 12 Jun 2025 | 482.00 | MERIDIAN HEALTH PLAN | CARC 96 · NON_COVERED | 0.00 |