VICTOR EVANS
Dependent on policy B03M000491
Claims
1
Attributed to this person
Charged
539.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
107.80
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 | VICTOR EVANS |
| Role on the policy | Dependent · relationship 01 |
| Policy | B03M000491 |
| Date of birth | 28 Apr 1947 |
| Plan | PLATINUM PPO |
| Covered from | 9 Oct 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 107.80 |
| Total | 107.80 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002040 | 31 Dec 2024 | 539.00 | NORTHSTAR MUTUAL | Not denied | — |