OMAR LOPEZ
Subscriber on policy B04M000203
Claims
3
Attributed to this person
Charged
1,554.00
Total submitted
Denied
402.00
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 | OMAR LOPEZ |
| Role on the policy | Subscriber |
| Policy | B04M000203 |
| Date of birth | 13 Sep 1960 |
| Plan | GOLD PPO |
| Covered from | 26 Mar 2024 |
| Covered to | 24 Jul 2024 |
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 |
|---|---|---|---|---|---|
| CLM0000902 | 10 Apr 2024 | 762.00 | MERIDIAN HEALTH PLAN | Not denied | — |
| CLM0000901 | 27 Mar 2024 | 390.00 | MERIDIAN HEALTH PLAN | Not denied | — |
| CLM0000903 | 17 Mar 2024 | 402.00 | MERIDIAN HEALTH PLAN | CARC 26 · ELIGIBILITY | 402.00 |