TOMAS LOPEZ
Dependent on policy B04M000352
Claims
2
Attributed to this person
Charged
1,177.00
Total submitted
Denied
163.34
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 | TOMAS LOPEZ |
| Role on the policy | Dependent · relationship 01 |
| Policy | B04M000352 |
| Date of birth | 1 Jan 1979 |
| Plan | SILVER HMO |
| Covered from | 3 Jun 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 |
|---|---|---|---|---|---|
| CLM0001508 | 6 Aug 2026 | 483.00 | CASCADE CARE | Not denied | — |
| CLM0001509 | 6 Jun 2024 | 694.00 | CASCADE CARE | CARC 27 · ELIGIBILITY | 163.34 |