RAVI LOPEZ
Dependent on policy B04M000012
Claims
1
Attributed to this person
Charged
319.00
Total submitted
Denied
319.00
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 | RAVI LOPEZ |
| Role on the policy | Dependent · relationship 19 |
| Policy | B04M000012 |
| Date of birth | 8 Jan 1999 |
| Plan | SILVER HMO |
| Covered from | 30 Mar 2024 |
| Covered to | 1 Sep 2024 |
Patient responsibility reported on the 835
No patient responsibility reported on this person's remittances.
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000063 | 21 Mar 2024 | 319.00 | CASCADE CARE | CARC 27 · ELIGIBILITY | 319.00 |