TOMAS WILSON
Dependent on policy B01M000086
Claims
3
Attributed to this person
Charged
837.00
Total submitted
Denied
204.00
1 denied claims
Patient responsibility
25.00
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 | TOMAS WILSON |
| Role on the policy | Dependent · relationship 01 |
| Policy | B01M000086 |
| Date of birth | 11 Nov 1983 |
| Plan | SILVER HMO |
| Covered from | 2 Mar 2024 |
| Covered to | 10 Aug 2024 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 3 · Copay | 1 | 25.00 |
| Total | 25.00 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000346 | 16 Jul 2024 | 204.00 | MERIDIAN HEALTH PLAN | CARC 197 · AUTHORIZATION | 204.00 |
| CLM0000344 | 19 Mar 2024 | 493.00 | MERIDIAN HEALTH PLAN | Not denied | — |
| CLM0000345 | 3 Mar 2024 | 140.00 | MERIDIAN HEALTH PLAN | Not denied | — |