UMA LOPEZ
Subscriber on policy B01M000764
Claims
1
Attributed to this person
Charged
458.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
68.70
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 | UMA LOPEZ |
| Role on the policy | Subscriber |
| Policy | B01M000764 |
| Date of birth | 28 Mar 1997 |
| Plan | SILVER HMO |
| Covered from | 13 Jan 2025 |
| Covered to | 30 May 2025 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 1 · Deductible | 1 | 68.70 |
| Total | 68.70 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0003399 | 28 Feb 2025 | 458.00 | CASCADE CARE | Not denied | — |