WENDY LOPEZ
Subscriber on policy B07M000761
Claims
3
Attributed to this person
Charged
1,038.00
Total submitted
Denied
526.00
2 denied claims
Patient responsibility
40.00
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 | WENDY LOPEZ |
| Role on the policy | Subscriber |
| Policy | B07M000761 |
| Date of birth | 18 Dec 1951 |
| Plan | BRONZE EPO |
| Covered from | 10 Mar 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 3 · Copay | 1 | 40.00 |
| Total | 40.00 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0003154 | 5 Aug 2026 | 127.00 | NORTHSTAR MUTUAL | CARC 11 · CODING | 127.00 |
| CLM0003153 | 4 Dec 2024 | 399.00 | NORTHSTAR MUTUAL | CARC 197 · AUTHORIZATION | 399.00 |
| CLM0003155 | 26 Oct 2024 | 512.00 | NORTHSTAR MUTUAL | Not denied | — |