CARLA LOPEZ
Dependent on policy B03M000062
Claims
2
Attributed to this person
Charged
279.00
Total submitted
Denied
279.00
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 | CARLA LOPEZ |
| Role on the policy | Dependent · relationship 19 |
| Policy | B03M000062 |
| Date of birth | 4 Feb 1999 |
| Plan | GOLD PPO |
| Covered from | 8 Nov 2024 |
| Covered to | 14 Jan 2025 |
Patient responsibility reported on the 835
No patient responsibility reported on this person's remittances.
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000268 | 21 Feb 2025 | 181.00 | NORTHSTAR MUTUAL | CARC 26 · ELIGIBILITY | 181.00 |
| CLM0000269 | 29 Oct 2024 | 98.00 | NORTHSTAR MUTUAL | CARC 26 · ELIGIBILITY | 98.00 |