VICTOR LOPEZ
Dependent on policy B08M000466
Claims
3
Attributed to this person
Charged
698.00
Total submitted
Denied
131.97
1 denied claims
Patient responsibility
34.80
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 | VICTOR LOPEZ |
| Role on the policy | Dependent · relationship 19 |
| Policy | B08M000466 |
| Date of birth | 23 Oct 2003 |
| Plan | SILVER HMO |
| Covered from | 16 Oct 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 1 · Deductible | 1 | 34.80 |
| Total | 34.80 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002150 | 13 Jun 2026 | 352.00 | NORTHSTAR MUTUAL | CARC 197 · AUTHORIZATION | 131.97 |
| CLM0002149 | 25 Mar 2025 | 232.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0002151 | 1 Jan 2025 | 114.00 | NORTHSTAR MUTUAL | Not denied | — |