ZARA LOPEZ
Dependent on policy B05M000695
Claims
3
Attributed to this person
Charged
1,458.00
Total submitted
Denied
125.00
2 denied claims
Patient responsibility
427.05
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 | ZARA LOPEZ |
| Role on the policy | Dependent · relationship 19 |
| Policy | B05M000695 |
| Date of birth | 1 Aug 2023 |
| Plan | GOLD PPO |
| Covered from | 27 Jan 2024 |
| Covered to | 25 Aug 2024 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 50 · Other | 1 | 427.05 |
| Total | 427.05 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002992 | 26 Aug 2024 | 125.00 | CASCADE CARE | CARC 27 · ELIGIBILITY | 125.00 |
| CLM0002991 | 15 Jul 2024 | 676.00 | CASCADE CARE | Not denied | — |
| CLM0002993 | 22 Mar 2024 | 657.00 | CASCADE CARE | CARC 50 · MEDICAL_NECESSITY | 0.00 |