VICTOR LOPEZ
Subscriber on policy B04M000294
Claims
1
Attributed to this person
Charged
285.00
Total submitted
Denied
0.00
1 denied claims
Patient responsibility
185.25
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 | VICTOR LOPEZ |
| Role on the policy | Subscriber |
| Policy | B04M000294 |
| Date of birth | 13 May 1961 |
| Plan | BRONZE EPO |
| Covered from | 8 Sep 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 96 · Other | 1 | 185.25 |
| Total | 185.25 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001272 | 10 Nov 2024 | 285.00 | NORTHSTAR MUTUAL | CARC 96 · NON_COVERED | 0.00 |