DAVID LOPEZ
Subscriber on policy B04M000710
Claims
3
Attributed to this person
Charged
1,718.00
Total submitted
Denied
718.00
1 denied claims
Patient responsibility
50.00
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 | DAVID LOPEZ |
| Role on the policy | Subscriber |
| Policy | B04M000710 |
| Date of birth | 9 Dec 2004 |
| Plan | GOLD PPO |
| Covered from | 1 Jun 2025 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 3 · Copay | 1 | 50.00 |
| Total | 50.00 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0003087 | 10 Jul 2026 | 448.00 | CASCADE CARE | Not denied | — |
| CLM0003086 | 3 Mar 2026 | 718.00 | CASCADE CARE | CARC 16 · BILLING_ERROR | 718.00 |
| CLM0003088 | 5 Aug 2025 | 552.00 | CASCADE CARE | Not denied | — |