CARLA LOPEZ
Subscriber on policy B03M000785
Claims
2
Attributed to this person
Charged
1,137.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
43.80
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 | Subscriber |
| Policy | B03M000785 |
| Date of birth | 26 Nov 1974 |
| Plan | PLATINUM PPO |
| Covered from | 14 Feb 2025 |
| Covered to | 21 Jun 2025 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 1 · Deductible | 1 | 43.80 |
| Total | 43.80 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0003337 | 20 Jun 2025 | 845.00 | CASCADE CARE | Not denied | — |
| CLM0003336 | 12 May 2025 | 292.00 | CASCADE CARE | Not denied | — |