WENDY SMITH
Dependent on policy B01M000288
Claims
3
Attributed to this person
Charged
1,869.00
Total submitted
Denied
109.59
2 denied claims
Patient responsibility
567.45
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 | WENDY SMITH |
| Role on the policy | Dependent · relationship 19 |
| Policy | B01M000288 |
| Date of birth | 12 Jul 2008 |
| Plan | PLATINUM PPO |
| Covered from | 20 Dec 2024 |
| Covered to | 18 Apr 2025 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 96 · Other | 1 | 567.45 |
| Total | 567.45 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001257 | 18 Apr 2025 | 711.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0001259 | 14 Apr 2025 | 285.00 | NORTHSTAR MUTUAL | CARC 50 · MEDICAL_NECESSITY | 109.59 |
| CLM0001258 | 25 Dec 2024 | 873.00 | NORTHSTAR MUTUAL | CARC 96 · NON_COVERED | 0.00 |