ELENA EVANS
Dependent on policy B04M000419
Claims
2
Attributed to this person
Charged
719.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
89.40
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 EVANS |
| Role on the policy | Dependent · relationship 19 |
| Policy | B04M000419 |
| Date of birth | 14 May 2010 |
| Plan | BRONZE EPO |
| Covered from | 13 Apr 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 89.40 |
| Total | 89.40 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001803 | 20 Dec 2024 | 272.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0001804 | 4 Jul 2024 | 447.00 | NORTHSTAR MUTUAL | Not denied | — |