OMAR LOPEZ
Dependent on policy B04M000542
Claims
3
Attributed to this person
Charged
1,972.00
Total submitted
Denied
853.00
1 denied claims
Patient responsibility
25.00
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 | OMAR LOPEZ |
| Role on the policy | Dependent · relationship 19 |
| Policy | B04M000542 |
| Date of birth | 21 May 2000 |
| Plan | GOLD PPO |
| Covered from | 22 Oct 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 3 · Copay | 1 | 25.00 |
| Total | 25.00 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002376 | 4 Jul 2025 | 229.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0002377 | 11 Apr 2025 | 890.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0002378 | 22 Oct 2024 | 853.00 | NORTHSTAR MUTUAL | CARC 197 · AUTHORIZATION | 853.00 |