ELENA EVANS
Dependent on policy B01M000268
Claims
3
Attributed to this person
Charged
1,986.00
Total submitted
Denied
811.00
2 denied claims
Patient responsibility
439.40
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 | ELENA EVANS |
| Role on the policy | Dependent · relationship 19 |
| Policy | B01M000268 |
| Date of birth | 22 Sep 2000 |
| Plan | SILVER HMO |
| Covered from | 13 Jun 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 96 · Other | 1 | 439.40 |
| Total | 439.40 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001146 | 11 Mar 2026 | 499.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0001147 | 10 Dec 2025 | 811.00 | NORTHSTAR MUTUAL | CARC 27 · ELIGIBILITY | 811.00 |
| CLM0001148 | 22 Jun 2024 | 676.00 | NORTHSTAR MUTUAL | CARC 96 · NON_COVERED | 0.00 |