YUSUF LOPEZ
Subscriber on policy B02M000849
Claims
1
Attributed to this person
Charged
276.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
55.20
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 | YUSUF LOPEZ |
| Role on the policy | Subscriber |
| Policy | B02M000849 |
| Date of birth | 4 Jun 1976 |
| Plan | GOLD PPO |
| Covered from | 15 Jan 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 55.20 |
| Total | 55.20 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0003530 | 29 Oct 2025 | 276.00 | NORTHSTAR MUTUAL | Not denied | — |