Patient Details
Back to List
Jason Doe Active
35 Years (10/25/1989)
|Gender:
Male
|
Marital
Status:
Married
|
Dependent
Of:
Alex Jenning
Member ID:
721533
Optum RX
Number:
1851351157445601
Patient Account
Number:
58894417
Contact Information
Home
Phone:
(915) 216-8365
Cell
Phone:
(915) 216-8745
Email:
jason.doe@gmail.com
Alt
Phone:
(915) 854-5478
Work
Phone:
(915) 854-5847
Email:
jason.doe@gmail.com
Address & Residence
Address:
13023 Aberdare Dr, EI
Paso, TX, 79928
Residence
Type:
Home
Apartment
#:
2548
Plan Details
Type:
Comprehensive Gold Dep
Information:
Domestic
Effective Date:
3/1/2018
Information:
Domestic
End Date:
10/31/2024
| Claim Number | Date of Service | Status | Total Charge | Allowed Charge | Member Responsibility | Five Point Responsibility |
|---|---|---|---|---|---|---|
| 222-027-R-000168-005 | 1/17/2024 | In Process | $1,344.00 | $0.0 | $1,344.00 | $0.0 |
| 222-027-R-000168-010 | 1/17/2024 | In Process | $1,344.00 | $0.0 | $1,344.00 | $0.0 |
| 222-027-R-000168-025 | 1/17/2024 | Denied | $1,344.00 | $0.0 | $1,344.00 | $0.0 |
| 222-027-R-000168-040 | 1/17/2024 | Paid | $1,344.00 | $0.0 | $1,344.00 | $0.0 |
| 222-027-R-000168-105 | 1/17/2024 | Paid | $1,344.00 | $0.0 | $1,344.00 | $0.0 |
| 222-027-R-000168-085 | 1/17/2024 | In Process | $1,344.00 | $0.0 | $1,344.00 | $0.0 |