ELENA TANAKA
Dependent on policy B04M000421
Claims
3
Attributed to this person
Charged
1,903.00
Total submitted
Denied
734.00
2 denied claims
Patient responsibility
205.40
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 TANAKA |
| Role on the policy | Dependent · relationship 01 |
| Policy | B04M000421 |
| Date of birth | 16 Feb 1966 |
| Plan | PLATINUM PPO |
| Covered from | 19 Nov 2024 |
| Covered to | 3 May 2025 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 50 · Other | 1 | 205.40 |
| Total | 205.40 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001817 | 26 Apr 2025 | 734.00 | NORTHSTAR MUTUAL | CARC 29 · TIMELY_FILING | 734.00 |
| CLM0001816 | 31 Mar 2025 | 853.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0001815 | 29 Oct 2024 | 316.00 | NORTHSTAR MUTUAL | CARC 50 · MEDICAL_NECESSITY | 0.00 |