GRACE LOPEZ
Dependent on policy B10M000477
Claims
3
Attributed to this person
Charged
1,734.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
50.00
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 19 |
| Policy | B10M000477 |
| Date of birth | 6 May 2000 |
| Plan | SILVER HMO |
| Covered from | 18 Feb 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 3 · Copay | 1 | 50.00 |
| Total | 50.00 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001979 | 15 Jul 2025 | 126.00 | MERIDIAN HEALTH PLAN | Not denied | — |
| CLM0001981 | 11 Apr 2025 | 717.00 | MERIDIAN HEALTH PLAN | Not denied | — |
| CLM0001980 | 24 Jun 2024 | 891.00 | MERIDIAN HEALTH PLAN | Not denied | — |