GRACE EVANS
Subscriber on policy B05M000041
Claims
1
Attributed to this person
Charged
143.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
28.60
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 | Subscriber |
| Policy | B05M000041 |
| Date of birth | 21 Apr 1955 |
| Plan | PLATINUM PPO |
| Covered from | 18 May 2025 |
| Covered to | 9 Mar 2026 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 28.60 |
| Total | 28.60 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000181 | 12 Jun 2025 | 143.00 | CASCADE CARE | Not denied | — |