CARLA LOPEZ
Subscriber on policy B01M000468
Claims
3
Attributed to this person
Charged
1,608.00
Total submitted
Denied
0.00
1 denied claims
Patient responsibility
294.95
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 | CARLA LOPEZ |
| Role on the policy | Subscriber |
| Policy | B01M000468 |
| Date of birth | 4 Nov 1996 |
| Plan | BRONZE EPO |
| Covered from | 11 Mar 2024 |
| Covered to | 3 Dec 2024 |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 50 · Other | 1 | 160.55 |
| CARC 2 · Coinsurance | 1 | 134.40 |
| Total | 294.95 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002087 | 19 Jan 2025 | 672.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0002085 | 24 Nov 2024 | 247.00 | NORTHSTAR MUTUAL | CARC 50 · MEDICAL_NECESSITY | 0.00 |
| CLM0002086 | 24 Apr 2024 | 689.00 | NORTHSTAR MUTUAL | Not denied | — |