GRACE LOPEZ
Subscriber on policy B04M000503
Claims
2
Attributed to this person
Charged
1,387.00
Total submitted
Denied
496.00
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 | B04M000503 |
| Date of birth | 1 Aug 2001 |
| Plan | SILVER HMO |
| Covered from | 29 Mar 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 |
|---|---|---|---|---|---|
| CLM0002160 | 8 Jul 2024 | 891.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0002161 | 24 Mar 2024 | 496.00 | NORTHSTAR MUTUAL | CARC 26 · ELIGIBILITY | 496.00 |