HENRY SMITH
Subscriber on policy B04M000467
Claims
2
Attributed to this person
Charged
1,005.00
Total submitted
Denied
375.00
2 denied claims
Patient responsibility
409.50
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 | HENRY SMITH |
| Role on the policy | Subscriber |
| Policy | B04M000467 |
| Date of birth | 29 Aug 1956 |
| Plan | BRONZE EPO |
| Covered from | 22 Apr 2025 |
| Covered to | 18 Nov 2025 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 50 · Other | 1 | 409.50 |
| Total | 409.50 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002002 | 25 Dec 2025 | 375.00 | NORTHSTAR MUTUAL | CARC 27 · ELIGIBILITY | 375.00 |
| CLM0002003 | 29 Jul 2025 | 630.00 | NORTHSTAR MUTUAL | CARC 50 · MEDICAL_NECESSITY | 0.00 |