IVAN LOPEZ
Dependent on policy B09M000813
Claims
3
Attributed to this person
Charged
1,616.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
103.60
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 | IVAN LOPEZ |
| Role on the policy | Dependent · relationship 01 |
| Policy | B09M000813 |
| Date of birth | 9 Sep 1969 |
| Plan | PLATINUM PPO |
| Covered from | 4 Sep 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 103.60 |
| Total | 103.60 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0003455 | 7 Nov 2025 | 518.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0003454 | 12 Feb 2025 | 870.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0003456 | 19 Oct 2024 | 228.00 | NORTHSTAR MUTUAL | Not denied | — |