HENRY LOPEZ
Dependent on policy B03M000785
Claims
3
Attributed to this person
Charged
970.00
Total submitted
Denied
265.00
1 denied claims
Patient responsibility
50.00
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 | HENRY LOPEZ |
| Role on the policy | Dependent · relationship 01 |
| Policy | B03M000785 |
| Date of birth | 1 Jan 1983 |
| Plan | PLATINUM PPO |
| Covered from | 14 Feb 2025 |
| Covered to | 21 Jun 2025 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 3 · Copay | 1 | 50.00 |
| Total | 50.00 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0003339 | 2 Jul 2025 | 265.00 | CASCADE CARE | CARC 27 · ELIGIBILITY | 265.00 |
| CLM0003338 | 15 Jun 2025 | 468.00 | CASCADE CARE | Not denied | — |
| CLM0003340 | 30 Jan 2025 | 237.00 | CASCADE CARE | Not denied | — |