HENRY SMITH
Dependent on policy B01M000123
Claims
3
Attributed to this person
Charged
1,879.00
Total submitted
Denied
333.00
1 denied claims
Patient responsibility
150.60
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 | HENRY SMITH |
| Role on the policy | Dependent · relationship 01 |
| Policy | B01M000123 |
| Date of birth | 14 Aug 1978 |
| Plan | BRONZE EPO |
| Covered from | 14 May 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 150.60 |
| Total | 150.60 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000477 | 13 Mar 2026 | 753.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0000478 | 19 Nov 2025 | 333.00 | NORTHSTAR MUTUAL | CARC 197 · AUTHORIZATION | 333.00 |
| CLM0000476 | 20 Oct 2024 | 793.00 | NORTHSTAR MUTUAL | Not denied | — |