CARLA LOPEZ
Dependent on policy B03M000804
Claims
1
Attributed to this person
Charged
348.00
Total submitted
Denied
348.00
1 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 | CARLA LOPEZ |
| Role on the policy | Dependent · relationship 01 |
| Policy | B03M000804 |
| Date of birth | 22 Mar 1982 |
| Plan | GOLD PPO |
| Covered from | 11 Jan 2024 |
| Covered to | 20 May 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 |
|---|---|---|---|---|---|
| CLM0003452 | 29 Dec 2023 | 348.00 | MERIDIAN HEALTH PLAN | CARC 26 · ELIGIBILITY | 348.00 |