GRACE EVANS
Dependent on policy B05M000298
Claims
3
Attributed to this person
Charged
690.00
Total submitted
Denied
0.00
2 denied claims
Patient responsibility
150.15
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 | GRACE EVANS |
| Role on the policy | Dependent · relationship 01 |
| Policy | B05M000298 |
| Date of birth | 14 Apr 1947 |
| Plan | SILVER HMO |
| Covered from | 21 Jul 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 96 · Other | 2 | 150.15 |
| Total | 150.15 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001234 | 28 Jan 2026 | 64.00 | NORTHSTAR MUTUAL | CARC 96 · NON_COVERED | 0.00 |
| CLM0001233 | 13 Jan 2026 | 459.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0001232 | 22 Sep 2025 | 167.00 | NORTHSTAR MUTUAL | CARC 96 · NON_COVERED | 0.00 |