TOMAS LOPEZ
Dependent on policy B10M000541
Claims
3
Attributed to this person
Charged
1,301.00
Total submitted
Denied
257.53
1 denied claims
Patient responsibility
67.95
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 | B10M000541 |
| Date of birth | 18 May 1988 |
| Plan | SILVER HMO |
| Covered from | 16 Apr 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 1 · Deductible | 1 | 67.95 |
| Total | 67.95 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002238 | 3 Mar 2026 | 629.00 | MERIDIAN HEALTH PLAN | CARC 18 · DUPLICATE | 257.53 |
| CLM0002239 | 23 Apr 2025 | 219.00 | MERIDIAN HEALTH PLAN | Not denied | — |
| CLM0002240 | 6 Mar 2025 | 453.00 | MERIDIAN HEALTH PLAN | Not denied | — |