TOMAS BAKER
Subscriber on policy B04M000696
Claims
2
Attributed to this person
Charged
1,139.00
Total submitted
Denied
614.00
2 denied claims
Patient responsibility
341.25
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 | TOMAS BAKER |
| Role on the policy | Subscriber |
| Policy | B04M000696 |
| Date of birth | 11 Jun 1974 |
| Plan | PLATINUM PPO |
| Covered from | 20 Dec 2024 |
| Covered to | 25 Sep 2025 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 50 · Other | 1 | 341.25 |
| Total | 341.25 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0003037 | 28 May 2025 | 525.00 | NORTHSTAR MUTUAL | CARC 50 · MEDICAL_NECESSITY | 0.00 |
| CLM0003038 | 19 Feb 2025 | 614.00 | NORTHSTAR MUTUAL | CARC 27 · ELIGIBILITY | 614.00 |