GRACE SMITH
Subscriber on policy B04M000842
Claims
3
Attributed to this person
Charged
1,685.00
Total submitted
Denied
1,133.00
2 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 | Subscriber |
| Policy | B04M000842 |
| Date of birth | 21 Dec 1985 |
| Plan | GOLD PPO |
| Covered from | 1 Jul 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 |
|---|---|---|---|---|---|
| CLM0003641 | 13 Apr 2026 | 552.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0003642 | 20 Jan 2026 | 587.00 | NORTHSTAR MUTUAL | CARC 96 · NON_COVERED | 587.00 |
| CLM0003640 | 30 Apr 2025 | 546.00 | NORTHSTAR MUTUAL | CARC 197 · AUTHORIZATION | 546.00 |