ELENA VARGAS
Dependent on policy B03M000192
Claims
2
Attributed to this person
Charged
938.00
Total submitted
Denied
22.06
1 denied claims
Patient responsibility
27.45
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 VARGAS |
| Role on the policy | Dependent · relationship 19 |
| Policy | B03M000192 |
| Date of birth | 19 Jan 1986 |
| Plan | SILVER HMO |
| Covered from | 9 Mar 2024 |
| Covered to | 10 Sep 2024 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 1 · Deductible | 1 | 27.45 |
| Total | 27.45 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000791 | 5 Nov 2024 | 183.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0000790 | 28 May 2024 | 755.00 | NORTHSTAR MUTUAL | CARC 50 · MEDICAL_NECESSITY | 22.06 |