ELENA LOPEZ
Subscriber on policy B10M000642
Claims
2
Attributed to this person
Charged
692.00
Total submitted
Denied
237.00
1 denied claims
Patient responsibility
91.00
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 | ELENA LOPEZ |
| Role on the policy | Subscriber |
| Policy | B10M000642 |
| Date of birth | 13 Mar 1959 |
| Plan | BRONZE EPO |
| Covered from | 31 Oct 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 91.00 |
| Total | 91.00 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002664 | 1 Nov 2025 | 455.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0002663 | 22 May 2025 | 237.00 | NORTHSTAR MUTUAL | CARC 27 · ELIGIBILITY | 237.00 |