LEILA SMITH
Dependent on policy B04M000865
Claims
1
Attributed to this person
Charged
285.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
57.00
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 | LEILA SMITH |
| Role on the policy | Dependent · relationship 19 |
| Policy | B04M000865 |
| Date of birth | 29 Jan 1990 |
| Plan | SILVER HMO |
| Covered from | 16 May 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 57.00 |
| Total | 57.00 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0003744 | 12 Aug 2025 | 285.00 | MERIDIAN HEALTH PLAN | Not denied | — |