OMAR LOPEZ
Dependent on policy B05M000049
Claims
3
Attributed to this person
Charged
2,526.00
Total submitted
Denied
809.00
1 denied claims
Patient responsibility
177.80
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 | B05M000049 |
| Date of birth | 11 Feb 2023 |
| Plan | GOLD PPO |
| Covered from | 12 Oct 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 177.80 |
| Total | 177.80 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000236 | 4 Jul 2026 | 889.00 | MERIDIAN HEALTH PLAN | Not denied | — |
| CLM0000235 | 20 Jan 2026 | 809.00 | MERIDIAN HEALTH PLAN | CARC 16 · BILLING_ERROR | 809.00 |
| CLM0000234 | 23 Oct 2024 | 828.00 | MERIDIAN HEALTH PLAN | Not denied | — |