TOMAS DIAZ
Dependent on policy B03M000685
Claims
2
Attributed to this person
Charged
1,135.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
15.00
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 | TOMAS DIAZ |
| Role on the policy | Dependent · relationship 01 |
| Policy | B03M000685 |
| Date of birth | 14 Feb 2006 |
| Plan | GOLD PPO |
| Covered from | 25 Aug 2024 |
| Covered to | 24 Oct 2024 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 3 · Copay | 1 | 15.00 |
| Total | 15.00 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002847 | 6 Oct 2024 | 714.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0002848 | 27 Jul 2024 | 421.00 | NORTHSTAR MUTUAL | Not denied | — |