RAVI SMITH
Subscriber on policy B03M000091
Claims
2
Attributed to this person
Charged
577.00
Total submitted
Denied
162.47
1 denied claims
Patient responsibility
34.05
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 | RAVI SMITH |
| Role on the policy | Subscriber |
| Policy | B03M000091 |
| Date of birth | 15 Nov 2004 |
| Plan | BRONZE EPO |
| Covered from | 15 Feb 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 1 · Deductible | 1 | 34.05 |
| Total | 34.05 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000376 | 6 Jun 2026 | 350.00 | NORTHSTAR MUTUAL | CARC 18 · DUPLICATE | 162.47 |
| CLM0000377 | 18 Dec 2024 | 227.00 | NORTHSTAR MUTUAL | Not denied | — |