GRACE LOPEZ
Dependent on policy B07M000141
Claims
3
Attributed to this person
Charged
2,127.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
86.55
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 | GRACE LOPEZ |
| Role on the policy | Dependent · relationship 01 |
| Policy | B07M000141 |
| Date of birth | 16 Feb 1985 |
| Plan | PLATINUM PPO |
| Covered from | 5 Jun 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 1 · Deductible | 1 | 86.55 |
| Total | 86.55 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000583 | 4 Nov 2025 | 577.00 | CASCADE CARE | Not denied | — |
| CLM0000584 | 14 Jul 2025 | 653.00 | CASCADE CARE | Not denied | — |
| CLM0000585 | 10 Apr 2025 | 897.00 | CASCADE CARE | Not denied | — |