LEILA LOPEZ
Subscriber on policy B05M000417
Claims
3
Attributed to this person
Charged
1,880.00
Total submitted
Denied
0.00
0 denied claims
Patient responsibility
129.15
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 | LEILA LOPEZ |
| Role on the policy | Subscriber |
| Policy | B05M000417 |
| Date of birth | 3 Sep 1994 |
| Plan | PLATINUM PPO |
| Covered from | 21 Jun 2025 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 1 · Deductible | 1 | 129.15 |
| Total | 129.15 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001756 | 29 Nov 2025 | 430.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0001755 | 21 Sep 2025 | 861.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0001757 | 20 Sep 2025 | 589.00 | NORTHSTAR MUTUAL | Not denied | — |