AMARA LOPEZ
Subscriber on policy B08M000152
Claims
2
Attributed to this person
Charged
1,582.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
179.60
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 | AMARA LOPEZ |
| Role on the policy | Subscriber |
| Policy | B08M000152 |
| Date of birth | 18 Oct 1992 |
| Plan | SILVER HMO |
| Covered from | 31 Mar 2024 |
| Covered to | 30 Sep 2024 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 179.60 |
| Total | 179.60 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000707 | 29 Apr 2024 | 898.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0000706 | 10 Apr 2024 | 684.00 | NORTHSTAR MUTUAL | Not denied | — |