TOMAS LOPEZ
Subscriber on policy B03M000116
Claims
1
Attributed to this person
Charged
629.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
94.35
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 | B03M000116 |
| Date of birth | 19 Feb 1997 |
| Plan | GOLD PPO |
| Covered from | 5 Jun 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 1 · Deductible | 1 | 94.35 |
| Total | 94.35 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000455 | 29 Jul 2024 | 629.00 | CASCADE CARE | Not denied | — |