TOMAS SMITH
Dependent on policy B04M000062
Claims
2
Attributed to this person
Charged
1,230.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
30.00
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 SMITH |
| Role on the policy | Dependent · relationship 19 |
| Policy | B04M000062 |
| Date of birth | 23 Sep 1984 |
| Plan | BRONZE EPO |
| Covered from | 4 May 2025 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 3 · Copay | 1 | 30.00 |
| Total | 30.00 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000273 | 8 May 2026 | 511.00 | CASCADE CARE | Not denied | — |
| CLM0000272 | 12 Dec 2025 | 719.00 | CASCADE CARE | Not denied | — |