TOMAS BAKER
Subscriber on policy B05M000188
Claims
1
Attributed to this person
Charged
891.00
Total submitted
Denied
0.00
1 denied claims
Patient responsibility
579.15
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 BAKER |
| Role on the policy | Subscriber |
| Policy | B05M000188 |
| Date of birth | 6 Mar 1959 |
| Plan | BRONZE EPO |
| Covered from | 21 Apr 2024 |
| Covered to | 9 Aug 2024 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 50 · Other | 1 | 579.15 |
| Total | 579.15 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000787 | 10 Apr 2024 | 891.00 | NORTHSTAR MUTUAL | CARC 50 · MEDICAL_NECESSITY | 0.00 |