TOMAS CHEN
Dependent on policy B03M000399
Claims
3
Attributed to this person
Charged
586.00
Total submitted
Denied
441.00
2 denied claims
Patient responsibility
21.75
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 | TOMAS CHEN |
| Role on the policy | Dependent · relationship 01 |
| Policy | B03M000399 |
| Date of birth | 28 Oct 1986 |
| Plan | SILVER HMO |
| Covered from | 8 Apr 2024 |
| Covered to | 10 Dec 2024 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 1 · Deductible | 1 | 21.75 |
| Total | 21.75 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001616 | 15 Dec 2024 | 145.00 | CASCADE CARE | Not denied | — |
| CLM0001617 | 12 Nov 2024 | 173.00 | CASCADE CARE | CARC 29 · TIMELY_FILING | 173.00 |
| CLM0001615 | 26 Apr 2024 | 268.00 | CASCADE CARE | CARC 18 · DUPLICATE | 268.00 |