BRIAN LOPEZ
Dependent on policy B06M000059
Claims
3
Attributed to this person
Charged
1,559.00
Total submitted
Denied
705.00
2 denied claims
Patient responsibility
170.80
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 | BRIAN LOPEZ |
| Role on the policy | Dependent · relationship 19 |
| Policy | B06M000059 |
| Date of birth | 28 Apr 2014 |
| Plan | PLATINUM PPO |
| Covered from | 14 Jan 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 2 · Coinsurance | 1 | 170.80 |
| Total | 170.80 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0000325 | 6 May 2025 | 854.00 | MERIDIAN HEALTH PLAN | Not denied | — |
| CLM0000323 | 19 Dec 2024 | 146.00 | MERIDIAN HEALTH PLAN | CARC 18 · DUPLICATE | 146.00 |
| CLM0000324 | 21 Apr 2024 | 559.00 | MERIDIAN HEALTH PLAN | CARC 197 · AUTHORIZATION | 559.00 |