DAVID JOHNSON
Dependent on policy B04M000260
Claims
3
Attributed to this person
Charged
2,168.00
Total submitted
Denied
855.00
1 denied claims
Patient responsibility
20.00
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 | DAVID JOHNSON |
| Role on the policy | Dependent · relationship 19 |
| Policy | B04M000260 |
| Date of birth | 23 Aug 2012 |
| Plan | SILVER HMO |
| Covered from | 6 Sep 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 3 · Copay | 1 | 20.00 |
| Total | 20.00 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001127 | 29 Sep 2025 | 795.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0001128 | 10 Jun 2025 | 518.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0001126 | 7 Oct 2024 | 855.00 | NORTHSTAR MUTUAL | CARC 29 · TIMELY_FILING | 855.00 |