TOMAS LOPEZ
Dependent on policy B01M000512
Claims
1
Attributed to this person
Charged
705.00
Total submitted
Denied
0.00
1 denied claims
Patient responsibility
458.25
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 | TOMAS LOPEZ |
| Role on the policy | Dependent · relationship 01 |
| Policy | B01M000512 |
| Date of birth | 8 May 1990 |
| Plan | BRONZE EPO |
| Covered from | 30 Mar 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 50 · Other | 1 | 458.25 |
| Total | 458.25 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002307 | 4 Sep 2025 | 705.00 | CASCADE CARE | CARC 50 · MEDICAL_NECESSITY | 0.00 |