YUSUF LOPEZ
Dependent on policy B06M000355
Claims
2
Attributed to this person
Charged
976.00
Total submitted
Denied
0.00
1 denied claims
Patient responsibility
102.05
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 | YUSUF LOPEZ |
| Role on the policy | Dependent · relationship 19 |
| Policy | B06M000355 |
| Date of birth | 13 Feb 2014 |
| Plan | SILVER HMO |
| Covered from | 23 Sep 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 96 · Other | 1 | 102.05 |
| Total | 102.05 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001613 | 24 Jan 2026 | 819.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0001614 | 9 Nov 2024 | 157.00 | NORTHSTAR MUTUAL | CARC 96 · NON_COVERED | 0.00 |