FIONA LOPEZ
Subscriber on policy B01M000302
Claims
3
Attributed to this person
Charged
1,758.00
Total submitted
Denied
872.00
1 denied claims
Patient responsibility
52.65
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 | FIONA LOPEZ |
| Role on the policy | Subscriber |
| Policy | B01M000302 |
| Date of birth | 19 Dec 1955 |
| Plan | PLATINUM PPO |
| Covered from | 12 Feb 2024 |
| Covered to | 3 Oct 2024 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 1 · Deductible | 1 | 52.65 |
| Total | 52.65 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001330 | 27 Nov 2024 | 351.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0001331 | 14 Nov 2024 | 872.00 | NORTHSTAR MUTUAL | CARC 27 · ELIGIBILITY | 872.00 |
| CLM0001332 | 7 Mar 2024 | 535.00 | NORTHSTAR MUTUAL | Not denied | — |