SOFIA LOPEZ
Dependent on policy B02M000542
Claims
3
Attributed to this person
Charged
1,462.00
Total submitted
Denied
0.00
1 denied claims
Patient responsibility
297.25
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 | SOFIA LOPEZ |
| Role on the policy | Dependent · relationship 19 |
| Policy | B02M000542 |
| Date of birth | 9 May 1982 |
| Plan | GOLD PPO |
| Covered from | 17 Jan 2025 |
| Covered to | 16 Aug 2025 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 50 · Other | 1 | 203.45 |
| CARC 2 · Coinsurance | 1 | 93.80 |
| Total | 297.25 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002298 | 7 Sep 2025 | 469.00 | CASCADE CARE | Not denied | — |
| CLM0002296 | 5 May 2025 | 680.00 | CASCADE CARE | Not denied | — |
| CLM0002297 | 9 Jan 2025 | 313.00 | CASCADE CARE | CARC 50 · MEDICAL_NECESSITY | 0.00 |