TOMAS REYES
Dependent on policy B04M000134
Claims
3
Attributed to this person
Charged
954.00
Total submitted
Denied
123.00
2 denied claims
Patient responsibility
407.55
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 | TOMAS REYES |
| Role on the policy | Dependent · relationship 01 |
| Policy | B04M000134 |
| Date of birth | 9 Aug 1974 |
| Plan | BRONZE EPO |
| Covered from | 14 Sep 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 50 · Other | 1 | 407.55 |
| Total | 407.55 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000617 | 12 May 2026 | 123.00 | NORTHSTAR MUTUAL | CARC 197 · AUTHORIZATION | 123.00 |
| CLM0000618 | 27 Sep 2024 | 204.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0000619 | 25 Sep 2024 | 627.00 | NORTHSTAR MUTUAL | CARC 50 · MEDICAL_NECESSITY | 0.00 |