TOMAS DIAZ
Subscriber on policy B05M000244
Claims
2
Attributed to this person
Charged
583.00
Total submitted
Denied
0.00
1 denied claims
Patient responsibility
265.20
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 DIAZ |
| Role on the policy | Subscriber |
| Policy | B05M000244 |
| Date of birth | 1 Jul 1951 |
| Plan | BRONZE EPO |
| Covered from | 29 Jun 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 96 · Other | 1 | 265.20 |
| Total | 265.20 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001008 | 31 Jul 2026 | 408.00 | NORTHSTAR MUTUAL | CARC 96 · NON_COVERED | 0.00 |
| CLM0001009 | 22 May 2025 | 175.00 | NORTHSTAR MUTUAL | Not denied | — |