GRACE LOPEZ
Subscriber on policy B10M000481
Claims
1
Attributed to this person
Charged
194.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
29.10
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 | Subscriber |
| Policy | B10M000481 |
| Date of birth | 4 Dec 1966 |
| Plan | GOLD PPO |
| Covered from | 8 Apr 2025 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 1 · Deductible | 1 | 29.10 |
| Total | 29.10 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001994 | 19 May 2026 | 194.00 | MERIDIAN HEALTH PLAN | Not denied | — |