TOMAS LOPEZ
Subscriber on policy B02M000514
Claims
3
Attributed to this person
Charged
1,987.00
Total submitted
Denied
811.11
2 denied claims
Patient responsibility
0.00
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 | TOMAS LOPEZ |
| Role on the policy | Subscriber |
| Policy | B02M000514 |
| Date of birth | 16 Sep 2001 |
| Plan | PLATINUM PPO |
| Covered from | 3 May 2024 |
| Covered to | open |
Patient responsibility reported on the 835
No patient responsibility reported on this person's remittances.
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002175 | 26 May 2025 | 588.00 | NORTHSTAR MUTUAL | CARC 16 · BILLING_ERROR | 123.11 |
| CLM0002177 | 3 Mar 2025 | 711.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0002176 | 28 Dec 2024 | 688.00 | NORTHSTAR MUTUAL | CARC 29 · TIMELY_FILING | 688.00 |