TOMAS ANDERSON
Subscriber on policy B04M000614
Claims
2
Attributed to this person
Charged
771.00
Total submitted
Denied
473.00
1 denied claims
Patient responsibility
59.60
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 | TOMAS ANDERSON |
| Role on the policy | Subscriber |
| Policy | B04M000614 |
| Date of birth | 15 Oct 1961 |
| Plan | GOLD PPO |
| Covered from | 9 Jan 2024 |
| Covered to | 11 Apr 2024 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 59.60 |
| Total | 59.60 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002683 | 4 May 2024 | 473.00 | CASCADE CARE | CARC 27 · ELIGIBILITY | 473.00 |
| CLM0002682 | 28 Jan 2024 | 298.00 | CASCADE CARE | Not denied | — |