GRACE SMITH
Dependent on policy B04M000758
Claims
1
Attributed to this person
Charged
169.00
Total submitted
Denied
169.00
1 denied claims
Patient responsibility
0.00
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 SMITH |
| Role on the policy | Dependent · relationship 19 |
| Policy | B04M000758 |
| Date of birth | 2 Feb 2007 |
| Plan | SILVER HMO |
| Covered from | 17 Aug 2024 |
| Covered to | open |
Patient responsibility reported on the 835
No patient responsibility reported on this person's remittances.
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0003306 | 7 Feb 2025 | 169.00 | NORTHSTAR MUTUAL | CARC 11 · CODING | 169.00 |