OMAR LOPEZ
Subscriber on policy B02M000400
Claims
2
Attributed to this person
Charged
462.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
20.00
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 | OMAR LOPEZ |
| Role on the policy | Subscriber |
| Policy | B02M000400 |
| Date of birth | 23 May 1959 |
| Plan | GOLD PPO |
| Covered from | 21 Dec 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 3 · Copay | 1 | 20.00 |
| Total | 20.00 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001719 | 18 Jun 2026 | 286.00 | CASCADE CARE | Not denied | — |
| CLM0001718 | 20 Feb 2026 | 176.00 | CASCADE CARE | Not denied | — |