GRACE EVANS
Subscriber on policy B04M000609
Claims
2
Attributed to this person
Charged
286.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
23.40
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 | GRACE EVANS |
| Role on the policy | Subscriber |
| Policy | B04M000609 |
| Date of birth | 30 Nov 1994 |
| Plan | BRONZE EPO |
| Covered from | 11 Feb 2025 |
| Covered to | 17 May 2025 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 1 · Deductible | 1 | 23.40 |
| Total | 23.40 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002666 | 14 Jun 2025 | 156.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0002665 | 10 Feb 2025 | 130.00 | NORTHSTAR MUTUAL | Not denied | — |