CARLA DIAZ
Subscriber on policy B01M000141
Claims
3
Attributed to this person
Charged
1,596.00
Total submitted
Denied
469.00
1 denied claims
Patient responsibility
85.20
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 | CARLA DIAZ |
| Role on the policy | Subscriber |
| Policy | B01M000141 |
| Date of birth | 5 Apr 1978 |
| Plan | BRONZE EPO |
| Covered from | 2 Nov 2024 |
| Covered to | 25 Apr 2025 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 85.20 |
| Total | 85.20 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000576 | 18 Jun 2025 | 426.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0000578 | 27 Apr 2025 | 469.00 | NORTHSTAR MUTUAL | CARC 27 · ELIGIBILITY | 469.00 |
| CLM0000577 | 17 Apr 2025 | 701.00 | NORTHSTAR MUTUAL | Not denied | — |