UMA SMITH
Dependent on policy B04M000075
Claims
2
Attributed to this person
Charged
495.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
86.55
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 | UMA SMITH |
| Role on the policy | Dependent · relationship 01 |
| Policy | B04M000075 |
| Date of birth | 11 Apr 1985 |
| Plan | SILVER HMO |
| Covered from | 13 Jun 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 49.20 |
| CARC 1 · Deductible | 1 | 37.35 |
| Total | 86.55 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000351 | 28 Mar 2025 | 249.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0000350 | 16 Nov 2024 | 246.00 | NORTHSTAR MUTUAL | Not denied | — |