TOMAS DIAZ
Dependent on policy B04M000244
Claims
3
Attributed to this person
Charged
1,245.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
30.00
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 | TOMAS DIAZ |
| Role on the policy | Dependent · relationship 01 |
| Policy | B04M000244 |
| Date of birth | 26 Nov 1952 |
| Plan | BRONZE EPO |
| Covered from | 16 Jun 2025 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 3 · Copay | 1 | 30.00 |
| Total | 30.00 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001069 | 6 Jul 2026 | 403.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0001071 | 25 May 2026 | 677.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0001070 | 16 Apr 2026 | 165.00 | NORTHSTAR MUTUAL | Not denied | — |