UMA LOPEZ
Subscriber on policy B03M000436
Claims
3
Attributed to this person
Charged
1,042.00
Total submitted
Denied
454.00
2 denied claims
Patient responsibility
88.20
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 | UMA LOPEZ |
| Role on the policy | Subscriber |
| Policy | B03M000436 |
| Date of birth | 19 Nov 1971 |
| Plan | PLATINUM PPO |
| Covered from | 1 May 2025 |
| Covered to | 17 Sep 2025 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 1 · Deductible | 1 | 88.20 |
| Total | 88.20 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001785 | 16 May 2025 | 588.00 | MERIDIAN HEALTH PLAN | Not denied | — |
| CLM0001784 | 29 Apr 2025 | 350.00 | MERIDIAN HEALTH PLAN | CARC 26 · ELIGIBILITY | 350.00 |
| CLM0001786 | 3 Apr 2025 | 104.00 | MERIDIAN HEALTH PLAN | CARC 26 · ELIGIBILITY | 104.00 |