UMA DIAZ
Subscriber on policy B03M000304
Claims
2
Attributed to this person
Charged
842.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
139.40
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 | UMA DIAZ |
| Role on the policy | Subscriber |
| Policy | B03M000304 |
| Date of birth | 22 Jun 1968 |
| Plan | GOLD PPO |
| Covered from | 4 Jul 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 139.40 |
| Total | 139.40 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001208 | 23 Apr 2026 | 145.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0001209 | 18 Jul 2024 | 697.00 | NORTHSTAR MUTUAL | Not denied | — |