LEILA EVANS
Dependent on policy B05M000155
Claims
2
Attributed to this person
Charged
892.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
25.00
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 | LEILA EVANS |
| Role on the policy | Dependent · relationship 01 |
| Policy | B05M000155 |
| Date of birth | 10 Aug 1970 |
| Plan | GOLD PPO |
| Covered from | 3 Jul 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 3 · Copay | 1 | 25.00 |
| Total | 25.00 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000649 | 8 Feb 2026 | 135.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0000648 | 11 Jan 2025 | 757.00 | NORTHSTAR MUTUAL | Not denied | — |