ELENA WILSON
Dependent on policy B04M000328
Claims
2
Attributed to this person
Charged
1,352.00
Total submitted
Denied
577.00
1 denied claims
Patient responsibility
155.00
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 | ELENA WILSON |
| Role on the policy | Dependent · relationship 01 |
| Policy | B04M000328 |
| Date of birth | 25 Sep 1946 |
| Plan | GOLD PPO |
| Covered from | 16 Mar 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 155.00 |
| Total | 155.00 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001425 | 2 Sep 2025 | 577.00 | MERIDIAN HEALTH PLAN | CARC 29 · TIMELY_FILING | 577.00 |
| CLM0001426 | 12 Nov 2024 | 775.00 | MERIDIAN HEALTH PLAN | Not denied | — |