BRIAN EVANS
Dependent on policy B04M000722
Claims
1
Attributed to this person
Charged
105.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
15.75
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 | BRIAN EVANS |
| Role on the policy | Dependent · relationship 01 |
| Policy | B04M000722 |
| Date of birth | 28 Oct 1954 |
| Plan | PLATINUM PPO |
| Covered from | 5 Apr 2024 |
| Covered to | 17 Nov 2024 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 1 · Deductible | 1 | 15.75 |
| Total | 15.75 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0003141 | 28 Apr 2024 | 105.00 | MERIDIAN HEALTH PLAN | Not denied | — |