TOMAS EVANS
Dependent on policy B03M000472
Claims
2
Attributed to this person
Charged
319.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
20.00
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 | TOMAS EVANS |
| Role on the policy | Dependent · relationship 19 |
| Policy | B03M000472 |
| Date of birth | 19 Dec 2004 |
| Plan | PLATINUM PPO |
| Covered from | 15 May 2025 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 3 · Copay | 1 | 20.00 |
| Total | 20.00 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001972 | 27 Jul 2025 | 93.00 | MERIDIAN HEALTH PLAN | Not denied | — |
| CLM0001971 | 29 Jun 2025 | 226.00 | MERIDIAN HEALTH PLAN | Not denied | — |