TOMAS SMITH
Dependent on policy B04M000652
Claims
3
Attributed to this person
Charged
1,434.00
Total submitted
Denied
750.00
2 denied claims
Patient responsibility
216.45
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 SMITH |
| Role on the policy | Dependent · relationship 19 |
| Policy | B04M000652 |
| Date of birth | 15 Jul 2022 |
| Plan | PLATINUM PPO |
| Covered from | 4 Jan 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 50 · Other | 1 | 216.45 |
| Total | 216.45 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002847 | 16 Jul 2026 | 333.00 | MERIDIAN HEALTH PLAN | CARC 50 · MEDICAL_NECESSITY | 0.00 |
| CLM0002845 | 16 Aug 2024 | 750.00 | MERIDIAN HEALTH PLAN | CARC 27 · ELIGIBILITY | 750.00 |
| CLM0002846 | 9 Jan 2024 | 351.00 | MERIDIAN HEALTH PLAN | Not denied | — |