GRACE LOPEZ
Dependent on policy B01M000477
Claims
2
Attributed to this person
Charged
865.00
Total submitted
Denied
124.00
2 denied claims
Patient responsibility
481.65
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 | GRACE LOPEZ |
| Role on the policy | Dependent · relationship 19 |
| Policy | B01M000477 |
| Date of birth | 1 Nov 1989 |
| Plan | PLATINUM PPO |
| Covered from | 24 Jun 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 96 · Other | 1 | 481.65 |
| Total | 481.65 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002126 | 29 Jun 2025 | 741.00 | CASCADE CARE | CARC 96 · NON_COVERED | 0.00 |
| CLM0002125 | 6 Jun 2024 | 124.00 | CASCADE CARE | CARC 26 · ELIGIBILITY | 124.00 |