LEILA LOPEZ
Subscriber on policy B02M000833
Claims
2
Attributed to this person
Charged
842.00
Total submitted
Denied
125.91
2 denied claims
Patient responsibility
264.55
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 | LEILA LOPEZ |
| Role on the policy | Subscriber |
| Policy | B02M000833 |
| Date of birth | 8 Jan 1953 |
| Plan | GOLD PPO |
| Covered from | 28 Jul 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 50 · Other | 1 | 264.55 |
| Total | 264.55 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0003459 | 28 Jan 2026 | 407.00 | MERIDIAN HEALTH PLAN | CARC 50 · MEDICAL_NECESSITY | 0.00 |
| CLM0003458 | 4 Sep 2024 | 435.00 | MERIDIAN HEALTH PLAN | CARC 96 · NON_COVERED | 125.91 |