ZARA EVANS
Dependent on policy B05M000046
Claims
3
Attributed to this person
Charged
2,067.00
Total submitted
Denied
255.15
2 denied claims
Patient responsibility
455.65
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 | ZARA EVANS |
| Role on the policy | Dependent · relationship 19 |
| Policy | B05M000046 |
| Date of birth | 30 Mar 2000 |
| Plan | PLATINUM PPO |
| Covered from | 18 Mar 2025 |
| Covered to | 3 Oct 2025 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 50 · Other | 1 | 455.65 |
| Total | 455.65 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000208 | 27 Aug 2025 | 775.00 | NORTHSTAR MUTUAL | CARC 11 · CODING | 255.15 |
| CLM0000210 | 19 Mar 2025 | 591.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0000209 | 26 Feb 2025 | 701.00 | NORTHSTAR MUTUAL | CARC 50 · MEDICAL_NECESSITY | 0.00 |