ELENA EVANS
Dependent on policy B03M000518
Claims
3
Attributed to this person
Charged
1,193.00
Total submitted
Denied
750.61
2 denied claims
Patient responsibility
0.00
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 | ELENA EVANS |
| Role on the policy | Dependent · relationship 01 |
| Policy | B03M000518 |
| Date of birth | 28 Jan 1952 |
| Plan | GOLD PPO |
| Covered from | 23 Jul 2024 |
| Covered to | 25 Feb 2025 |
Patient responsibility reported on the 835
No patient responsibility reported on this person's remittances.
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002127 | 21 Nov 2024 | 710.00 | NORTHSTAR MUTUAL | CARC 27 · ELIGIBILITY | 710.00 |
| CLM0002128 | 8 Nov 2024 | 158.00 | NORTHSTAR MUTUAL | CARC 26 · ELIGIBILITY | 40.61 |
| CLM0002126 | 18 Sep 2024 | 325.00 | NORTHSTAR MUTUAL | Not denied | — |