PRIYA LOPEZ
Dependent on policy B03M000064
Claims
2
Attributed to this person
Charged
1,274.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
80.85
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 | PRIYA LOPEZ |
| Role on the policy | Dependent · relationship 19 |
| Policy | B03M000064 |
| Date of birth | 8 May 2021 |
| Plan | BRONZE EPO |
| Covered from | 10 Oct 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 1 · Deductible | 1 | 80.85 |
| Total | 80.85 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000278 | 3 Sep 2025 | 735.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0000277 | 7 Jan 2025 | 539.00 | NORTHSTAR MUTUAL | Not denied | — |