GRACE GARCIA
Dependent on policy B03M000264
Claims
2
Attributed to this person
Charged
972.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
40.00
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 | GRACE GARCIA |
| Role on the policy | Dependent · relationship 01 |
| Policy | B03M000264 |
| Date of birth | 15 Jun 1943 |
| Plan | GOLD PPO |
| Covered from | 27 Apr 2025 |
| Covered to | 16 Feb 2026 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 3 · Copay | 1 | 40.00 |
| Total | 40.00 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001066 | 6 Sep 2025 | 630.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0001065 | 2 Jul 2025 | 342.00 | NORTHSTAR MUTUAL | Not denied | — |