CARLA LOPEZ
Dependent on policy B04M000542
Claims
1
Attributed to this person
Charged
115.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
23.00
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 | CARLA LOPEZ |
| Role on the policy | Dependent · relationship 19 |
| Policy | B04M000542 |
| Date of birth | 9 Apr 1993 |
| Plan | GOLD PPO |
| Covered from | 22 Oct 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 23.00 |
| Total | 23.00 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002379 | 16 May 2026 | 115.00 | NORTHSTAR MUTUAL | Not denied | — |