GRACE LOPEZ
Subscriber on policy B02M000549
Claims
3
Attributed to this person
Charged
1,236.00
Total submitted
Denied
873.67
2 denied claims
Patient responsibility
25.00
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 | GRACE LOPEZ |
| Role on the policy | Subscriber |
| Policy | B02M000549 |
| Date of birth | 14 Oct 2004 |
| Plan | SILVER HMO |
| Covered from | 17 May 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 3 · Copay | 1 | 25.00 |
| Total | 25.00 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002320 | 16 Apr 2026 | 789.00 | MERIDIAN HEALTH PLAN | CARC 27 · ELIGIBILITY | 789.00 |
| CLM0002319 | 14 Feb 2026 | 242.00 | MERIDIAN HEALTH PLAN | CARC 27 · ELIGIBILITY | 84.67 |
| CLM0002318 | 25 Apr 2024 | 205.00 | MERIDIAN HEALTH PLAN | Not denied | — |