PRIYA DIAZ
Dependent on policy B05M000801
Claims
2
Attributed to this person
Charged
390.00
Total submitted
Denied
71.67
1 denied claims
Patient responsibility
18.20
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 | PRIYA DIAZ |
| Role on the policy | Dependent · relationship 19 |
| Policy | B05M000801 |
| Date of birth | 10 Oct 1974 |
| Plan | SILVER HMO |
| Covered from | 14 Mar 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 18.20 |
| Total | 18.20 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0003394 | 15 Jan 2026 | 91.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0003395 | 5 Feb 2025 | 299.00 | NORTHSTAR MUTUAL | CARC 197 · AUTHORIZATION | 71.67 |