GRACE LOPEZ
Subscriber on policy B04M000403
Claims
2
Attributed to this person
Charged
1,534.00
Total submitted
Denied
803.00
1 denied claims
Patient responsibility
0.00
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 | GRACE LOPEZ |
| Role on the policy | Subscriber |
| Policy | B04M000403 |
| Date of birth | 6 Sep 1975 |
| Plan | PLATINUM PPO |
| Covered from | 28 Apr 2025 |
| Covered to | 20 Jul 2025 |
Patient responsibility reported on the 835
No patient responsibility reported on this person's remittances.
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001726 | 9 Sep 2025 | 731.00 | MERIDIAN HEALTH PLAN | Not denied | — |
| CLM0001727 | 28 Jul 2025 | 803.00 | MERIDIAN HEALTH PLAN | CARC 27 · ELIGIBILITY | 803.00 |