FIONA LOPEZ
Dependent on policy B03M000530
Claims
1
Attributed to this person
Charged
603.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
90.45
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 | FIONA LOPEZ |
| Role on the policy | Dependent · relationship 01 |
| Policy | B03M000530 |
| Date of birth | 18 Oct 1980 |
| Plan | BRONZE EPO |
| Covered from | 6 Feb 2025 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 1 · Deductible | 1 | 90.45 |
| Total | 90.45 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002171 | 13 Apr 2026 | 603.00 | NORTHSTAR MUTUAL | Not denied | — |