DAVID SMITH
Subscriber on policy B03M000038
Claims
3
Attributed to this person
Charged
2,050.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
219.95
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 | DAVID SMITH |
| Role on the policy | Subscriber |
| Policy | B03M000038 |
| Date of birth | 12 Aug 1954 |
| Plan | BRONZE EPO |
| Covered from | 27 Sep 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 155.00 |
| CARC 1 · Deductible | 1 | 64.95 |
| Total | 219.95 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000163 | 12 Jun 2026 | 775.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0000162 | 15 May 2026 | 842.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0000164 | 10 Nov 2024 | 433.00 | NORTHSTAR MUTUAL | Not denied | — |