ELENA LOPEZ
Dependent on policy B03M000680
Claims
2
Attributed to this person
Charged
370.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
15.00
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 | ELENA LOPEZ |
| Role on the policy | Dependent · relationship 01 |
| Policy | B03M000680 |
| Date of birth | 19 Apr 1992 |
| Plan | SILVER HMO |
| Covered from | 7 Jun 2025 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 15.00 |
| Total | 15.00 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002830 | 27 Jul 2025 | 75.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0002829 | 22 May 2025 | 295.00 | NORTHSTAR MUTUAL | Not denied | — |