DAVID LOPEZ
Subscriber on policy B01M000357
Claims
1
Attributed to this person
Charged
165.00
Total submitted
Denied
0.00
1 denied claims
Patient responsibility
107.25
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 | DAVID LOPEZ |
| Role on the policy | Subscriber |
| Policy | B01M000357 |
| Date of birth | 10 Sep 2000 |
| Plan | SILVER HMO |
| Covered from | 12 Apr 2025 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 96 · Other | 1 | 107.25 |
| Total | 107.25 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001576 | 25 Feb 2026 | 165.00 | CASCADE CARE | CARC 96 · NON_COVERED | 0.00 |