AMARA LOPEZ
Subscriber on policy B05M000360
Claims
2
Attributed to this person
Charged
804.00
Total submitted
Denied
0.00
1 denied claims
Patient responsibility
436.80
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 | AMARA LOPEZ |
| Role on the policy | Subscriber |
| Policy | B05M000360 |
| Date of birth | 8 Jun 1955 |
| Plan | BRONZE EPO |
| Covered from | 27 Mar 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 96 · Other | 1 | 436.80 |
| Total | 436.80 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001535 | 19 Nov 2025 | 132.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0001536 | 28 Feb 2024 | 672.00 | NORTHSTAR MUTUAL | CARC 96 · NON_COVERED | 0.00 |