ELENA GARCIA
Dependent on policy B04M000290
Claims
2
Attributed to this person
Charged
1,340.00
Total submitted
Denied
466.00
1 denied claims
Patient responsibility
174.80
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 | ELENA GARCIA |
| Role on the policy | Dependent · relationship 01 |
| Policy | B04M000290 |
| Date of birth | 1 Nov 1989 |
| Plan | BRONZE EPO |
| Covered from | 19 Aug 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 174.80 |
| Total | 174.80 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001254 | 24 Mar 2025 | 874.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0001255 | 14 Oct 2024 | 466.00 | NORTHSTAR MUTUAL | CARC 197 · AUTHORIZATION | 466.00 |