AMARA SMITH
Dependent on policy B04M000505
Claims
2
Attributed to this person
Charged
618.00
Total submitted
Denied
508.00
2 denied claims
Patient responsibility
71.50
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 | AMARA SMITH |
| Role on the policy | Dependent · relationship 01 |
| Policy | B04M000505 |
| Date of birth | 22 Oct 1986 |
| Plan | GOLD PPO |
| Covered from | 25 Jan 2025 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 96 · Other | 1 | 71.50 |
| Total | 71.50 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002172 | 7 Aug 2025 | 110.00 | NORTHSTAR MUTUAL | CARC 96 · NON_COVERED | 0.00 |
| CLM0002173 | 30 May 2025 | 508.00 | NORTHSTAR MUTUAL | CARC 27 · ELIGIBILITY | 508.00 |