RAVI LOPEZ
Dependent on policy B05M000480
Claims
3
Attributed to this person
Charged
882.00
Total submitted
Denied
283.08
2 denied claims
Patient responsibility
65.00
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 | B05M000480 |
| Date of birth | 27 Mar 1986 |
| Plan | PLATINUM PPO |
| Covered from | 18 May 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 65.00 |
| Total | 65.00 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002019 | 15 Jan 2026 | 385.00 | MERIDIAN HEALTH PLAN | CARC 197 · AUTHORIZATION | 111.08 |
| CLM0002021 | 15 Oct 2025 | 325.00 | MERIDIAN HEALTH PLAN | Not denied | — |
| CLM0002020 | 15 Aug 2024 | 172.00 | MERIDIAN HEALTH PLAN | CARC 197 · AUTHORIZATION | 172.00 |