TOMAS LOPEZ
Subscriber on policy B03M000137
Claims
3
Attributed to this person
Charged
1,371.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
40.00
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 | B03M000137 |
| Date of birth | 11 Dec 1967 |
| Plan | PLATINUM PPO |
| Covered from | 19 Aug 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 3 · Copay | 1 | 40.00 |
| Total | 40.00 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000548 | 6 Jul 2026 | 585.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0000546 | 30 Dec 2024 | 310.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0000547 | 12 Oct 2024 | 476.00 | NORTHSTAR MUTUAL | Not denied | — |