TOMAS LOPEZ
Dependent on policy B04M000837
Claims
3
Attributed to this person
Charged
2,331.00
Total submitted
Denied
1,664.00
2 denied claims
Patient responsibility
100.05
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 | TOMAS LOPEZ |
| Role on the policy | Dependent · relationship 01 |
| Policy | B04M000837 |
| Date of birth | 9 Nov 1963 |
| Plan | GOLD PPO |
| Covered from | 10 Jan 2025 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 1 · Deductible | 1 | 100.05 |
| Total | 100.05 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0003619 | 4 Aug 2026 | 667.00 | MERIDIAN HEALTH PLAN | Not denied | — |
| CLM0003621 | 31 Dec 2024 | 886.00 | MERIDIAN HEALTH PLAN | CARC 26 · ELIGIBILITY | 886.00 |
| CLM0003620 | 13 Dec 2024 | 778.00 | MERIDIAN HEALTH PLAN | CARC 26 · ELIGIBILITY | 778.00 |