DAVID LOPEZ
Dependent on policy B10M000274
Claims
1
Attributed to this person
Charged
631.00
Total submitted
Denied
135.42
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 | DAVID LOPEZ |
| Role on the policy | Dependent · relationship 19 |
| Policy | B10M000274 |
| Date of birth | 21 Apr 2023 |
| Plan | PLATINUM PPO |
| Covered from | 24 Jun 2024 |
| Covered to | 3 Sep 2024 |
Patient responsibility reported on the 835
No patient responsibility reported on this person's remittances.
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001146 | 14 Jul 2024 | 631.00 | MERIDIAN HEALTH PLAN | CARC 27 · ELIGIBILITY | 135.42 |