TOMAS LOPEZ
Dependent on policy B01M000468
Claims
2
Attributed to this person
Charged
1,097.00
Total submitted
Denied
584.00
1 denied claims
Patient responsibility
0.00
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 | TOMAS LOPEZ |
| Role on the policy | Dependent · relationship 01 |
| Policy | B01M000468 |
| Date of birth | 28 Mar 2000 |
| Plan | BRONZE EPO |
| Covered from | 11 Mar 2024 |
| Covered to | 3 Dec 2024 |
Patient responsibility reported on the 835
No patient responsibility reported on this person's remittances.
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0002088 | 8 Dec 2024 | 584.00 | NORTHSTAR MUTUAL | CARC 27 · ELIGIBILITY | 584.00 |
| CLM0002089 | 7 Oct 2024 | 513.00 | NORTHSTAR MUTUAL | Not denied | — |