AccountId: 011433970860
ContactId: a48eb204-6621-48c7-8d8f-49419ce15458
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 964070 ms
Total Talk Time (AGENT): 510814 ms
Total Talk Time (CUSTOMER): 261224 ms
Interruptions: 2
Overall Sentiment: AGENT=0.1, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/14/a48eb204-6621-48c7-8d8f-49419ce15458_20250514T15:06_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How can I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] from APL care team. I have a [PII] on the line from SSN Health, and she is asking about one of the claims that they gave and wondering about the deductible. It, it looks like it might have been charged, we might have charged them from the major medical instead of their um Medlink policy, and I was wondering if you could help her out with that and help me out with that.
[AGENT][NEUTRAL] Certainly, um, [PII], what's the policy number?
[CUSTOMER][NEUTRAL] OK. The
[CUSTOMER][NEUTRAL] 02
[CUSTOMER][NEUTRAL] 14
[CUSTOMER][NEUTRAL] 1802.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And the claim number?
[CUSTOMER][NEUTRAL] It's 3566.
[CUSTOMER][NEUTRAL] 644.
[AGENT][NEUTRAL] And it's for [PII], correct?
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] 356-664-4 OK.
[CUSTOMER][NEUTRAL] And it looked like their major medical healthy Alliance.
[AGENT][NEUTRAL] OK, let me pull up that mail number.
[CUSTOMER][NEUTRAL] Looking at the documents that they have.
[AGENT][NEUTRAL] Yeah, I'm gonna pull up the documents so just bear with me for one moment.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] It's taking just a minute to load.
[AGENT][NEUTRAL] So it looks like they also have a a deductible on their meddling policy that they must satisfy before um.
[CUSTOMER][NEUTRAL] I'm sorry, yeah.
[AGENT][NEUTRAL] Let me just take a look here.
[AGENT][NEUTRAL] So it was applied
[CUSTOMER][NEUTRAL] Yeah, and then when I looked.
[AGENT][NEUTRAL] 4 1865 from their major medical deductible.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] That's, that's what it looked like to me and then if I look in CLHBP it's not even showing that.
[CUSTOMER][NEUTRAL] Because this is a um.
[CUSTOMER][NEUTRAL] This is a cardiac.
[CUSTOMER][NEUTRAL] Testing done in a facility as well, so it wasn't the other ones that got denied. It looked like we only paid so much towards this one.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, it will
[CUSTOMER][NEUTRAL] And she said there's like there's still a balance left of about $3000 if I could heard her right?
[AGENT][NEUTRAL] OK, so I'm pulling up her policy now, so just bear with me for one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so they do have, um, under this policy they do have that $1000 deductible that has to be met before we would cover any of the um services. So what happened is under this particular claim we applied that 41865 to their $1000 deductible under their Medlink policy.
[AGENT][NEUTRAL] Um, so that's why they're, yes, so they have, of course they have, um, now I'm not sure if you're familiar how the medlink policy works. So the medlink policy will cover the co-insurance and deductible for services covered under the plan up to their maximum, which under their maximum on this plan for outpatient is $5000. However, they do need to meet that $1000 deductible with the APL policy first.
[CUSTOMER][NEUTRAL] Under their med link
[AGENT][NEUTRAL] So if you look on let's see.
[CUSTOMER][POSITIVE] And I am also, this is my first, this is actually my 2nd day, um, so I'm still learning all of these things.
[AGENT][NEUTRAL] Yeah, that's OK, yeah, so if you look under um the PIBFT screen it does show that they do have uh let's see that.
[AGENT][NEUTRAL] $1000 deductible that's due for outpatient um I don't know if did you look at their policy at all or you just looked on the screens that are available in online?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I did, I did look at the PIBST and then I even looked at the EOB.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] And it's, it's still not making sense why they have that to me why they have that $2000 left over and I was wondering if you would also be able to better explain it to her as you're explaining it to me and I'm trying to figure this out.
[AGENT][NEUTRAL] Certainly, so, um.
[CUSTOMER][NEUTRAL] Cause it wasn't an office, was it?
[AGENT][NEUTRAL] Yeah, um, because it was outpatient, um, facility charges, so, um, like I said there, so their charge was, let's see, 2700 I believe or no I'm sorry, 66428 was the total charges and then when you look at the explanation of benefits from the primary insurance.
[AGENT][NEUTRAL] They allowed that 41865 but applied it to her major medical deductible. So then in most situations that when that claim came to us we would pay that $41865. However, they do need to meet their $1000 deductible with our plan with the medling plan. So go ahead and give me, um, you said it was [PII] is her name?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And what's the callback number just so I can reference it, [PII]?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, and if you wanna go ahead and put her through and then I'll explain it to her and if you wanna listen in that's perfectly fine.
[CUSTOMER][POSITIVE] OK, thank you so much one moment.
[AGENT][POSITIVE] And, and, and if you need any assistance in the future just let me know I'd be happy to help you any way I can.
[CUSTOMER][NEUTRAL] I'm, I'm sorry, I see that here. Oh no, I'm I'm sorry I'm transferring you over to claims support and she's going to explain that to you yeah yeah OK thank you yes.
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] Hi [PII].
[AGENT][NEUTRAL] Hi, [PII]. My name is [PII]. Hi, my name is [PII] and I'm on the claim support team. It's [PII] Last initial is [PII].
[CUSTOMER][NEUTRAL] Yes, hello.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So, um, what, um, um, I was explaining to [PII] is that we did receive the claim um for their policy that um they have with us, um, this particular policy does have a $1000 deductible for their secondary plan that must be meant for outpatient services before um this plan would pay. So normally this plan works like a.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Like a gap policy that will cover co-insurance and or deductible amounts for services covered under the plan up to their benefit maximum. However, they do have a $1000 outpatient deductible again that needs to be met before um any benefits will be paid under this plan.
[AGENT][NEUTRAL] So we applied the 4 1865 to their deductible so against their $1000 excuse me, $1000 deductible with us with the meddling plan.
[CUSTOMER][NEGATIVE] I guess I, but I don't understand if she has $1000 deductible and you only applied for 19, she obviously must have met her deductible somewhere else, so why was the balance not paid?
[AGENT][NEUTRAL] No, I'm sorry, the deductible with us has not met. That's why, so the allowed amount um if you look at the primary insurance, uh, explanation of benefits that was sent for this claim, the allowed amount was 41865 and it was a.
[AGENT][NEUTRAL] Applied to her deductible, so she has a major medical deductible, but under this plan with us she also has to meet a $1000 deductible so that 41865 was applied to her $1000 deductible with us with the APL plan and then uh I'm showing year to date she has met 51102 of that $1000 year to date.
[CUSTOMER][NEUTRAL] Oh, OK, so the primary insurance applied $4,371.04 to her deductible.
[CUSTOMER][NEUTRAL] Then we sent it to you guys and you applied for 1865 to her deductible, but it leaves a balance of 3,95239 so I'm trying to see.
[CUSTOMER][NEUTRAL] Why there's a balance and if she if you only applied for 1865.
[CUSTOMER][NEUTRAL] To our deductible that's $1000 why?
[AGENT][NEUTRAL] Am I looking
[AGENT][NEUTRAL] Am I looking at the correct um.
[AGENT][NEUTRAL] Am I looking at the correct date of service? I'm showing the charges were.
[AGENT][NEUTRAL] 6428. However, the EOB only shows the um the code the MRI it looks like I believe it 70551. Let me look at that.
[AGENT][NEUTRAL] Do we have the right data service?
[CUSTOMER][NEUTRAL] Yes, 121 or 25.
[AGENT][NEUTRAL] And it was for an outpatient MRI outpatient diagnostic, correct?
[CUSTOMER][NEUTRAL] And it was for a um.
[CUSTOMER][NEUTRAL] Yes, but it, it was a cardiology um testing.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I'm gonna just bear with me for one moment because this EOB that's attached here does not match what is on the claim, so bear with me for just one moment.
[AGENT][NEUTRAL] Yeah, I'm not certain what happened here because it looks like the explanation of benefits doesn't match what's on the claim when this was processed so and you're saying that what was the total charges?
[CUSTOMER][NEUTRAL] The explanation that benefits from the primary.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Are you, are you seeing the explanation of benefits from the primary insurance?
[AGENT][NEUTRAL] Yeah, the one I'm received for this claim, the 356-664-4. I'm actually showing that um.
[CUSTOMER][NEUTRAL] OK, let me go
[AGENT][NEGATIVE] Yeah, it's not the correct amount. That's why there's a discrepancy it looks like because this EOB that's attached here is actually for a different patient and for data service 122 2025 and it does not match um what is billed on the UBO4 form um it's showing me a different procedure, so that's why I think we have a discrepancy.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Well, the EOB that I show.
[CUSTOMER][POSITIVE] Is correct, from the primary insurance.
[CUSTOMER][NEUTRAL] And I show that um.
[CUSTOMER][NEUTRAL] The UB that we sent you guys was for the correct amount.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] And you're saying the total charges are the 6428, right? 6,428, and what was the allowed amount?
[CUSTOMER][NEUTRAL] Yes, yes.
[CUSTOMER][NEUTRAL] And the allowed amount, $4,371.04.
[CUSTOMER][NEUTRAL] And they applied that to her deductible.
[CUSTOMER][NEUTRAL] And we sent the um EOB from uh Healthy Alliance Blue Cross Anthem Blue Cross. Do you have that?
[AGENT][NEUTRAL] No, and that's what I'm saying this actual that you'll be this attached. It does say Health Alliance Life.
[AGENT][NEUTRAL] Um, and it does say it came through the clearing house, but it actually has a different patient information on it. It has a different patient account, uh, let's see, patient account number is different, and that's what I'm saying, so I'm not sure what happened um when this was processed, but it was not processed correctly because the explanation of benefits that's attached to this claim does not match again the patient information or the charge amount um.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And that's why, like I said, we have a discrepancy here. So, um, I would advise to go ahead and send us a corrected explanation, uh, the primary explanation of benefits, um, and I'm going to send this back through for review, but we are gonna need that explanation of benefits from the primary insurance that matches this state of service.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Do you have
[CUSTOMER][NEUTRAL] OK, do you have a um.
[CUSTOMER][NEUTRAL] Uh, fax number I can send it to?
[AGENT][NEUTRAL] I do and that's what I was just gonna ask you if you wanted a fax and I can send I can give you our uh secure fax line and you can send that EOB over and like I said, I'll have the claim reviewed and reprocessed um with that correct information. So our fax number is gonna be [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 365.
[AGENT][NEUTRAL] 942 3.
[CUSTOMER][NEUTRAL] Alright, and do you have a reference number for our call?
[AGENT][NEUTRAL] Certainly [PII] you would use my name in today's date and again it's [PII] and that last [PII] today's date, um, and usually that turnaround time for reprocessing is like a 1 to 3 business days um but as soon as we receive that EOB we can go ahead and get the claim reprocessed but um we will need that EOB so that we can match it to the total charges that are on the UBO uh UBO4 form.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][POSITIVE] All righty. That sounds great. Thank you so much. I appreciate your help.
[AGENT][NEUTRAL] You're welcome, and [PII], just to verify that callback number just in case we need to contact you uh [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Alright, great, and I'll go ahead and notate the uh patient's file and like I said we'll get this reviewed um just need you to go ahead and uh send that corrected you'll be over.
[CUSTOMER][POSITIVE] Alrighty I can do that thank you so much.
[AGENT][NEUTRAL] You're welcome did you have any other questions?
[CUSTOMER][NEUTRAL] No, not today.
[AGENT][POSITIVE] Alright, thank you so much for your patience, [PII]. Thank you for calling APL. I hope you have a great day.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][POSITIVE] You too thank you bye.
[AGENT][NEUTRAL] OK, bye bye.