OMAR LOPEZ
Dependent on policy B08M000370
Claims
2
Attributed to this person
Charged
412.00
Total submitted
Denied
80.00
2 denied claims
Patient responsibility
215.80
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 | OMAR LOPEZ |
| Role on the policy | Dependent · relationship 19 |
| Policy | B08M000370 |
| Date of birth | 1 Jun 2022 |
| Plan | GOLD PPO |
| Covered from | 20 Jul 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 50 · Other | 1 | 215.80 |
| Total | 215.80 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001685 | 16 Oct 2025 | 332.00 | CASCADE CARE | CARC 50 · MEDICAL_NECESSITY | 0.00 |
| CLM0001684 | 25 Nov 2024 | 80.00 | CASCADE CARE | CARC 26 · ELIGIBILITY | 80.00 |