VICTOR LOPEZ
Subscriber on policy B10M000039
Claims
2
Attributed to this person
Charged
576.00
Total submitted
Denied
403.00
2 denied claims
Patient responsibility
112.45
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 | VICTOR LOPEZ |
| Role on the policy | Subscriber |
| Policy | B10M000039 |
| Date of birth | 1 Aug 1960 |
| Plan | SILVER HMO |
| Covered from | 5 Jan 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 50 · Other | 1 | 112.45 |
| Total | 112.45 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000154 | 15 Apr 2026 | 403.00 | NORTHSTAR MUTUAL | CARC 27 · ELIGIBILITY | 403.00 |
| CLM0000153 | 28 Feb 2025 | 173.00 | NORTHSTAR MUTUAL | CARC 50 · MEDICAL_NECESSITY | 0.00 |