RAVI DIAZ
Subscriber on policy B03M000738
Claims
3
Attributed to this person
Charged
1,175.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
28.40
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 | RAVI DIAZ |
| Role on the policy | Subscriber |
| Policy | B03M000738 |
| Date of birth | 21 Jan 1995 |
| Plan | GOLD PPO |
| Covered from | 10 Feb 2025 |
| Covered to | 23 May 2025 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 28.40 |
| Total | 28.40 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0003086 | 17 Jul 2025 | 142.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0003088 | 18 May 2025 | 498.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0003087 | 8 May 2025 | 535.00 | NORTHSTAR MUTUAL | Not denied | — |