UMA LOPEZ
Dependent on policy B04M000072
Claims
2
Attributed to this person
Charged
760.00
Total submitted
Denied
602.00
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 | UMA LOPEZ |
| Role on the policy | Dependent · relationship 19 |
| Policy | B04M000072 |
| Date of birth | 3 Aug 2022 |
| Plan | PLATINUM PPO |
| Covered from | 22 Sep 2024 |
| 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 |
|---|---|---|---|---|---|
| CLM0000341 | 26 Apr 2026 | 158.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0000340 | 1 Nov 2024 | 602.00 | NORTHSTAR MUTUAL | CARC 197 · AUTHORIZATION | 602.00 |