VICTOR USMAN
Dependent on policy B03M000875
Claims
2
Attributed to this person
Charged
976.00
Total submitted
Denied
811.00
1 denied claims
Patient responsibility
24.75
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 | VICTOR USMAN |
| Role on the policy | Dependent · relationship 19 |
| Policy | B03M000875 |
| Date of birth | 4 Dec 2012 |
| Plan | BRONZE EPO |
| Covered from | 11 Oct 2024 |
| Covered to | 2 Jan 2025 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 1 · Deductible | 1 | 24.75 |
| Total | 24.75 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0003801 | 13 Dec 2024 | 165.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0003802 | 2 Oct 2024 | 811.00 | NORTHSTAR MUTUAL | CARC 26 · ELIGIBILITY | 811.00 |