GRACE LOPEZ
Subscriber on policy B03M000227
Claims
1
Attributed to this person
Charged
297.00
Total submitted
Denied
297.00
1 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 | GRACE LOPEZ |
| Role on the policy | Subscriber |
| Policy | B03M000227 |
| Date of birth | 22 Sep 1974 |
| Plan | BRONZE EPO |
| Covered from | 7 Mar 2025 |
| Covered to | 25 May 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 |
|---|---|---|---|---|---|
| CLM0000925 | 5 Mar 2025 | 297.00 | NORTHSTAR MUTUAL | CARC 26 · ELIGIBILITY | 297.00 |