BRIAN DIAZ
Dependent on policy B01M000238
Claims
2
Attributed to this person
Charged
789.00
Total submitted
Denied
624.00
1 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 | BRIAN DIAZ |
| Role on the policy | Dependent · relationship 01 |
| Policy | B01M000238 |
| Date of birth | 16 Apr 1967 |
| Plan | BRONZE EPO |
| Covered from | 16 Feb 2024 |
| Covered to | 21 Sep 2024 |
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 |
|---|---|---|---|---|---|
| CLM0001005 | 13 Aug 2024 | 165.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0001004 | 20 Jan 2024 | 624.00 | NORTHSTAR MUTUAL | CARC 26 · ELIGIBILITY | 624.00 |