TOMAS DIAZ
Dependent on policy B03M000551
Claims
2
Attributed to this person
Charged
480.00
Total submitted
Denied
130.00
2 denied claims
Patient responsibility
227.50
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 DIAZ |
| Role on the policy | Dependent · relationship 01 |
| Policy | B03M000551 |
| Date of birth | 2 Mar 1995 |
| Plan | GOLD PPO |
| Covered from | 21 Jan 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 96 · Other | 1 | 227.50 |
| Total | 227.50 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002263 | 5 Mar 2026 | 130.00 | MERIDIAN HEALTH PLAN | CARC 18 · DUPLICATE | 130.00 |
| CLM0002264 | 31 Oct 2024 | 350.00 | MERIDIAN HEALTH PLAN | CARC 96 · NON_COVERED | 0.00 |