TOMAS LOPEZ
Subscriber on policy B09M000033
Claims
3
Attributed to this person
Charged
1,499.00
Total submitted
Denied
0.00
1 denied claims
Patient responsibility
358.15
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 | TOMAS LOPEZ |
| Role on the policy | Subscriber |
| Policy | B09M000033 |
| Date of birth | 20 Oct 1998 |
| Plan | PLATINUM PPO |
| Covered from | 19 Sep 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 50 · Other | 1 | 358.15 |
| Total | 358.15 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000149 | 16 Nov 2025 | 672.00 | MERIDIAN HEALTH PLAN | Not denied | — |
| CLM0000148 | 8 Jun 2025 | 276.00 | MERIDIAN HEALTH PLAN | Not denied | — |
| CLM0000147 | 7 Nov 2024 | 551.00 | MERIDIAN HEALTH PLAN | CARC 50 · MEDICAL_NECESSITY | 0.00 |