LEILA REYES
Dependent on policy B05M000743
Claims
3
Attributed to this person
Charged
333.00
Total submitted
Denied
64.00
2 denied claims
Patient responsibility
83.35
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 REYES |
| Role on the policy | Dependent · relationship 01 |
| Policy | B05M000743 |
| Date of birth | 27 Aug 1980 |
| Plan | BRONZE EPO |
| Covered from | 9 May 2025 |
| Covered to | 18 Sep 2025 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 96 · Other | 1 | 55.90 |
| CARC 1 · Deductible | 1 | 27.45 |
| Total | 83.35 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0003168 | 22 Oct 2025 | 86.00 | NORTHSTAR MUTUAL | CARC 96 · NON_COVERED | 0.00 |
| CLM0003167 | 1 Jul 2025 | 183.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0003169 | 9 Jun 2025 | 64.00 | NORTHSTAR MUTUAL | CARC 18 · DUPLICATE | 64.00 |