RAVI LOPEZ
Subscriber on policy B07M000439
Claims
2
Attributed to this person
Charged
601.00
Total submitted
Denied
328.00
1 denied claims
Patient responsibility
40.95
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 | RAVI LOPEZ |
| Role on the policy | Subscriber |
| Policy | B07M000439 |
| Date of birth | 6 Jun 2004 |
| Plan | BRONZE EPO |
| Covered from | 4 May 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 1 · Deductible | 1 | 40.95 |
| Total | 40.95 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001855 | 4 Feb 2026 | 328.00 | MERIDIAN HEALTH PLAN | CARC 197 · AUTHORIZATION | 328.00 |
| CLM0001854 | 3 Sep 2024 | 273.00 | MERIDIAN HEALTH PLAN | Not denied | — |