FIONA DIAZ
Dependent on policy B04M000296
Claims
1
Attributed to this person
Charged
413.00
Total submitted
Denied
0.00
1 denied claims
Patient responsibility
268.45
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 | FIONA DIAZ |
| Role on the policy | Dependent · relationship 01 |
| Policy | B04M000296 |
| Date of birth | 29 May 2001 |
| Plan | BRONZE EPO |
| Covered from | 25 May 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 96 · Other | 1 | 268.45 |
| Total | 268.45 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001278 | 25 Sep 2024 | 413.00 | NORTHSTAR MUTUAL | CARC 96 · NON_COVERED | 0.00 |