TOMAS LOPEZ
Subscriber on policy B03M000064
Claims
1
Attributed to this person
Charged
613.00
Total submitted
Denied
0.00
0 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 | TOMAS LOPEZ |
| Role on the policy | Subscriber |
| Policy | B03M000064 |
| Date of birth | 14 Apr 2002 |
| Plan | BRONZE EPO |
| Covered from | 10 Oct 2024 |
| Covered to | open |
Patient responsibility reported on the 835
No patient responsibility reported on this person's remittances.
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000275 | 15 Aug 2025 | 613.00 | NORTHSTAR MUTUAL | Not denied | — |