AMARA DIAZ
Subscriber on policy B04M000139
Claims
2
Attributed to this person
Charged
1,127.00
Total submitted
Denied
467.00
1 denied claims
Patient responsibility
99.00
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 | AMARA DIAZ |
| Role on the policy | Subscriber |
| Policy | B04M000139 |
| Date of birth | 1 Jul 1960 |
| Plan | PLATINUM PPO |
| Covered from | 7 Apr 2025 |
| Covered to | 27 Oct 2025 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 1 · Deductible | 1 | 99.00 |
| Total | 99.00 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000642 | 25 Oct 2025 | 467.00 | NORTHSTAR MUTUAL | CARC 27 · ELIGIBILITY | 467.00 |
| CLM0000641 | 28 Aug 2025 | 660.00 | NORTHSTAR MUTUAL | Not denied | — |