TOMAS LOPEZ
Subscriber on policy B07M000870
Claims
3
Attributed to this person
Charged
1,487.00
Total submitted
Denied
822.00
2 denied claims
Patient responsibility
99.75
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 | TOMAS LOPEZ |
| Role on the policy | Subscriber |
| Policy | B07M000870 |
| Date of birth | 9 Jul 2003 |
| Plan | SILVER HMO |
| Covered from | 18 Aug 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 1 · Deductible | 1 | 99.75 |
| Total | 99.75 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0003595 | 23 Mar 2026 | 105.00 | MERIDIAN HEALTH PLAN | CARC 26 · ELIGIBILITY | 105.00 |
| CLM0003596 | 20 Mar 2026 | 717.00 | MERIDIAN HEALTH PLAN | CARC 18 · DUPLICATE | 717.00 |
| CLM0003597 | 25 Dec 2025 | 665.00 | MERIDIAN HEALTH PLAN | Not denied | — |