CARLA LOPEZ
Dependent on policy B03M000680
Claims
3
Attributed to this person
Charged
1,022.00
Total submitted
Denied
0.00
1 denied claims
Patient responsibility
79.30
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 | CARLA LOPEZ |
| Role on the policy | Dependent · relationship 19 |
| Policy | B03M000680 |
| Date of birth | 18 Feb 2006 |
| Plan | SILVER HMO |
| Covered from | 7 Jun 2025 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 50 · Other | 1 | 79.30 |
| Total | 79.30 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002831 | 6 Jul 2026 | 122.00 | NORTHSTAR MUTUAL | CARC 50 · MEDICAL_NECESSITY | 0.00 |
| CLM0002833 | 6 Sep 2025 | 545.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0002832 | 9 Jun 2025 | 355.00 | NORTHSTAR MUTUAL | Not denied | — |