RAVI LOPEZ
Dependent on policy B09M000465
Claims
3
Attributed to this person
Charged
1,565.00
Total submitted
Denied
568.00
1 denied claims
Patient responsibility
108.15
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 | RAVI LOPEZ |
| Role on the policy | Dependent · relationship 01 |
| Policy | B09M000465 |
| Date of birth | 10 Jun 1966 |
| Plan | BRONZE EPO |
| Covered from | 6 Mar 2024 |
| Covered to | 9 Jul 2024 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 1 · Deductible | 1 | 108.15 |
| Total | 108.15 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001965 | 11 Jul 2024 | 568.00 | NORTHSTAR MUTUAL | CARC 27 · ELIGIBILITY | 568.00 |
| CLM0001963 | 29 Apr 2024 | 276.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0001964 | 3 Mar 2024 | 721.00 | NORTHSTAR MUTUAL | Not denied | — |