HENRY LOPEZ
Dependent on policy B08M000268
Claims
3
Attributed to this person
Charged
1,631.00
Total submitted
Denied
620.00
3 denied claims
Patient responsibility
657.15
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 | HENRY LOPEZ |
| Role on the policy | Dependent · relationship 01 |
| Policy | B08M000268 |
| Date of birth | 17 Jun 1993 |
| Plan | PLATINUM PPO |
| Covered from | 3 Jan 2025 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 96 · Other | 2 | 657.15 |
| Total | 657.15 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001217 | 14 May 2026 | 620.00 | CASCADE CARE | CARC 27 · ELIGIBILITY | 620.00 |
| CLM0001216 | 20 Aug 2025 | 410.00 | CASCADE CARE | CARC 96 · NON_COVERED | 0.00 |
| CLM0001218 | 14 Jul 2025 | 601.00 | CASCADE CARE | CARC 96 · NON_COVERED | 0.00 |