IVAN LOPEZ
Dependent on policy B08M000755
Claims
3
Attributed to this person
Charged
1,826.00
Total submitted
Denied
0.00
1 denied claims
Patient responsibility
469.95
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 01 |
| Policy | B08M000755 |
| Date of birth | 27 Jan 1984 |
| Plan | PLATINUM PPO |
| Covered from | 12 Mar 2025 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 50 · Other | 1 | 469.95 |
| Total | 469.95 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0003367 | 16 Jun 2026 | 209.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0003365 | 25 Oct 2025 | 723.00 | NORTHSTAR MUTUAL | CARC 50 · MEDICAL_NECESSITY | 0.00 |
| CLM0003366 | 27 Jul 2025 | 894.00 | NORTHSTAR MUTUAL | Not denied | — |