PRIYA LOPEZ
Dependent on policy B01M000536
Claims
2
Attributed to this person
Charged
323.00
Total submitted
Denied
106.00
1 denied claims
Patient responsibility
32.55
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 LOPEZ |
| Role on the policy | Dependent · relationship 19 |
| Policy | B01M000536 |
| Date of birth | 17 Dec 2002 |
| Plan | PLATINUM PPO |
| Covered from | 16 Jan 2025 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 1 · Deductible | 1 | 32.55 |
| Total | 32.55 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002411 | 4 Jul 2026 | 217.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0002410 | 8 Oct 2025 | 106.00 | NORTHSTAR MUTUAL | CARC 27 · ELIGIBILITY | 106.00 |