HENRY LOPEZ
Subscriber on policy B02M000736
Claims
3
Attributed to this person
Charged
1,232.00
Total submitted
Denied
909.00
2 denied claims
Patient responsibility
48.45
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 | HENRY LOPEZ |
| Role on the policy | Subscriber |
| Policy | B02M000736 |
| Date of birth | 12 Aug 1971 |
| Plan | PLATINUM PPO |
| Covered from | 11 Feb 2025 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 1 · Deductible | 1 | 48.45 |
| Total | 48.45 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0003075 | 7 Oct 2025 | 202.00 | MERIDIAN HEALTH PLAN | CARC 18 · DUPLICATE | 202.00 |
| CLM0003074 | 22 Jun 2025 | 323.00 | MERIDIAN HEALTH PLAN | Not denied | — |
| CLM0003073 | 9 Feb 2025 | 707.00 | MERIDIAN HEALTH PLAN | CARC 26 · ELIGIBILITY | 707.00 |