HENRY EVANS
Subscriber on policy B01M000413
Claims
2
Attributed to this person
Charged
449.00
Total submitted
Denied
258.00
1 denied claims
Patient responsibility
30.00
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 | HENRY EVANS |
| Role on the policy | Subscriber |
| Policy | B01M000413 |
| Date of birth | 21 May 2003 |
| Plan | GOLD PPO |
| Covered from | 16 Jan 2025 |
| Covered to | 1 Aug 2025 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 3 · Copay | 1 | 30.00 |
| Total | 30.00 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001829 | 18 Aug 2025 | 258.00 | NORTHSTAR MUTUAL | CARC 27 · ELIGIBILITY | 258.00 |
| CLM0001828 | 15 Mar 2025 | 191.00 | NORTHSTAR MUTUAL | Not denied | — |