OMAR GARCIA
Subscriber on policy B03M000684
Claims
1
Attributed to this person
Charged
120.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
24.00
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 | OMAR GARCIA |
| Role on the policy | Subscriber |
| Policy | B03M000684 |
| Date of birth | 1 Aug 1971 |
| Plan | PLATINUM PPO |
| Covered from | 16 Jun 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 24.00 |
| Total | 24.00 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002845 | 29 Mar 2025 | 120.00 | NORTHSTAR MUTUAL | Not denied | — |