ELENA USMAN
Subscriber on policy B03M000752
Claims
2
Attributed to this person
Charged
914.00
Total submitted
Denied
0.00
1 denied claims
Patient responsibility
553.45
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 | ELENA USMAN |
| Role on the policy | Subscriber |
| Policy | B03M000752 |
| Date of birth | 14 Aug 1987 |
| Plan | GOLD PPO |
| Covered from | 9 Sep 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 50 · Other | 1 | 528.45 |
| CARC 3 · Copay | 1 | 25.00 |
| Total | 553.45 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0003154 | 28 Oct 2025 | 101.00 | MERIDIAN HEALTH PLAN | Not denied | — |
| CLM0003155 | 17 Dec 2024 | 813.00 | MERIDIAN HEALTH PLAN | CARC 50 · MEDICAL_NECESSITY | 0.00 |