FIONA LOPEZ
Subscriber on policy B08M000728
Claims
3
Attributed to this person
Charged
1,797.00
Total submitted
Denied
0.00
1 denied claims
Patient responsibility
424.55
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 | FIONA LOPEZ |
| Role on the policy | Subscriber |
| Policy | B08M000728 |
| Date of birth | 1 Mar 1960 |
| Plan | PLATINUM PPO |
| Covered from | 21 Dec 2024 |
| Covered to | 27 Jul 2025 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 50 · Other | 1 | 394.55 |
| CARC 3 · Copay | 1 | 30.00 |
| Total | 424.55 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0003266 | 6 Apr 2025 | 876.00 | MERIDIAN HEALTH PLAN | Not denied | — |
| CLM0003265 | 5 Apr 2025 | 607.00 | MERIDIAN HEALTH PLAN | CARC 50 · MEDICAL_NECESSITY | 0.00 |
| CLM0003264 | 6 Jan 2025 | 314.00 | MERIDIAN HEALTH PLAN | Not denied | — |