CARLA DIAZ
Subscriber on policy B01M000411
Claims
3
Attributed to this person
Charged
1,870.00
Total submitted
Denied
620.00
1 denied claims
Patient responsibility
50.00
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 | CARLA DIAZ |
| Role on the policy | Subscriber |
| Policy | B01M000411 |
| Date of birth | 5 Aug 2000 |
| Plan | GOLD PPO |
| Covered from | 5 Dec 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 3 · Copay | 1 | 50.00 |
| Total | 50.00 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001819 | 16 Nov 2025 | 620.00 | NORTHSTAR MUTUAL | CARC 29 · TIMELY_FILING | 620.00 |
| CLM0001817 | 22 Aug 2025 | 461.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0001818 | 21 Jan 2025 | 789.00 | NORTHSTAR MUTUAL | Not denied | — |