GRACE LOPEZ
Subscriber on policy B04M000837
Claims
1
Attributed to this person
Charged
322.00
Total submitted
Denied
322.00
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 | B04M000837 |
| Date of birth | 13 Oct 1971 |
| Plan | GOLD PPO |
| Covered from | 10 Jan 2025 |
| Covered to | open |
Patient responsibility reported on the 835
No patient responsibility reported on this person's remittances.
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0003618 | 19 Jul 2025 | 322.00 | MERIDIAN HEALTH PLAN | CARC 18 · DUPLICATE | 322.00 |