IVAN LOPEZ
Dependent on policy B08M000158
Claims
1
Attributed to this person
Charged
380.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
57.00
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 | IVAN LOPEZ |
| Role on the policy | Dependent · relationship 19 |
| Policy | B08M000158 |
| Date of birth | 14 Jul 2021 |
| Plan | SILVER HMO |
| Covered from | 19 Jun 2025 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 1 · Deductible | 1 | 57.00 |
| Total | 57.00 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000721 | 23 Jan 2026 | 380.00 | NORTHSTAR MUTUAL | Not denied | — |