TOMAS WILSON
Subscriber on policy B05M000174
Claims
2
Attributed to this person
Charged
1,551.00
Total submitted
Denied
684.00
1 denied claims
Patient responsibility
173.40
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 | TOMAS WILSON |
| Role on the policy | Subscriber |
| Policy | B05M000174 |
| Date of birth | 27 Aug 1984 |
| Plan | BRONZE EPO |
| Covered from | 22 Jul 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 173.40 |
| Total | 173.40 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000733 | 28 Dec 2024 | 867.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0000734 | 10 Dec 2024 | 684.00 | NORTHSTAR MUTUAL | CARC 27 · ELIGIBILITY | 684.00 |