CARLA LOPEZ
Dependent on policy B09M000171
Claims
1
Attributed to this person
Charged
673.00
Total submitted
Denied
0.00
1 denied claims
Patient responsibility
437.45
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 | CARLA LOPEZ |
| Role on the policy | Dependent · relationship 19 |
| Policy | B09M000171 |
| Date of birth | 23 Jan 2013 |
| Plan | GOLD PPO |
| Covered from | 1 Feb 2025 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 50 · Other | 1 | 437.45 |
| Total | 437.45 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000715 | 16 Apr 2026 | 673.00 | NORTHSTAR MUTUAL | CARC 50 · MEDICAL_NECESSITY | 0.00 |