UMA LOPEZ
Dependent on policy B03M000806
Claims
1
Attributed to this person
Charged
512.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
76.80
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 | Dependent · relationship 19 |
| Policy | B03M000806 |
| Date of birth | 16 Oct 1989 |
| Plan | BRONZE EPO |
| Covered from | 2 Apr 2025 |
| Covered to | 28 Oct 2025 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 1 · Deductible | 1 | 76.80 |
| Total | 76.80 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0003468 | 5 Mar 2025 | 512.00 | MERIDIAN HEALTH PLAN | Not denied | — |