GRACE LOPEZ
Dependent on policy B09M000755
Claims
1
Attributed to this person
Charged
407.00
Total submitted
Denied
407.00
1 denied claims
Patient responsibility
0.00
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 01 |
| Policy | B09M000755 |
| Date of birth | 20 Apr 1999 |
| Plan | SILVER HMO |
| Covered from | 27 Sep 2024 |
| Covered to | open |
Patient responsibility reported on the 835
No patient responsibility reported on this person's remittances.
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0003195 | 10 Feb 2026 | 407.00 | NORTHSTAR MUTUAL | CARC 18 · DUPLICATE | 407.00 |