GRACE DIAZ
Dependent on policy B04M000311
Claims
2
Attributed to this person
Charged
936.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
40.00
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 | GRACE DIAZ |
| Role on the policy | Dependent · relationship 01 |
| Policy | B04M000311 |
| Date of birth | 29 Jun 1981 |
| Plan | GOLD PPO |
| Covered from | 17 Jan 2025 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 3 · Copay | 1 | 40.00 |
| Total | 40.00 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001365 | 6 May 2025 | 219.00 | MERIDIAN HEALTH PLAN | Not denied | — |
| CLM0001364 | 14 Jan 2025 | 717.00 | MERIDIAN HEALTH PLAN | Not denied | — |