PRIYA DIAZ
Subscriber on policy B03M000479
Claims
2
Attributed to this person
Charged
1,097.00
Total submitted
Denied
124.84
1 denied claims
Patient responsibility
133.60
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 | PRIYA DIAZ |
| Role on the policy | Subscriber |
| Policy | B03M000479 |
| Date of birth | 13 May 1954 |
| Plan | PLATINUM PPO |
| Covered from | 24 Mar 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 133.60 |
| Total | 133.60 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001997 | 2 Mar 2026 | 429.00 | NORTHSTAR MUTUAL | CARC 197 · AUTHORIZATION | 124.84 |
| CLM0001996 | 5 Mar 2025 | 668.00 | NORTHSTAR MUTUAL | Not denied | — |