RAVI REYES
Subscriber on policy B04M000279
Claims
1
Attributed to this person
Charged
328.00
Total submitted
Denied
0.00
1 denied claims
Patient responsibility
213.20
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 | RAVI REYES |
| Role on the policy | Subscriber |
| Policy | B04M000279 |
| Date of birth | 21 Mar 1981 |
| Plan | BRONZE EPO |
| Covered from | 18 Mar 2024 |
| Covered to | 30 Jul 2024 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 50 · Other | 1 | 213.20 |
| Total | 213.20 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001201 | 8 May 2024 | 328.00 | NORTHSTAR MUTUAL | CARC 50 · MEDICAL_NECESSITY | 0.00 |