DAVID LOPEZ
Subscriber on policy B03M000174
Claims
2
Attributed to this person
Charged
860.00
Total submitted
Denied
860.00
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 | DAVID LOPEZ |
| Role on the policy | Subscriber |
| Policy | B03M000174 |
| Date of birth | 24 Feb 1960 |
| Plan | GOLD PPO |
| Covered from | 21 Feb 2024 |
| Covered to | 28 Sep 2024 |
Patient responsibility reported on the 835
No patient responsibility reported on this person's remittances.
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000704 | 12 Nov 2024 | 137.00 | MERIDIAN HEALTH PLAN | CARC 27 · ELIGIBILITY | 137.00 |
| CLM0000703 | 11 Oct 2024 | 723.00 | MERIDIAN HEALTH PLAN | CARC 27 · ELIGIBILITY | 723.00 |