DAVID CHEN
Dependent on policy B03M000542
Claims
3
Attributed to this person
Charged
2,142.00
Total submitted
Denied
865.00
1 denied claims
Patient responsibility
108.60
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 | DAVID CHEN |
| Role on the policy | Dependent · relationship 01 |
| Policy | B03M000542 |
| Date of birth | 13 Aug 1949 |
| Plan | SILVER HMO |
| Covered from | 26 Jun 2024 |
| Covered to | 1 Nov 2024 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 108.60 |
| Total | 108.60 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002234 | 22 Oct 2024 | 543.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0002233 | 19 Jul 2024 | 734.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0002235 | 20 Jun 2024 | 865.00 | NORTHSTAR MUTUAL | CARC 26 · ELIGIBILITY | 865.00 |