AccountId: 011433970860
ContactId: e557f081-eaed-4347-9f37-b47380fe439c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1954130 ms
Total Talk Time (AGENT): 409523 ms
Total Talk Time (CUSTOMER): 696874 ms
Interruptions: 2
Overall Sentiment: AGENT=0.1, CUSTOMER=-1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/14/e557f081-eaed-4347-9f37-b47380fe439c_20250514T14:48_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, one second.
[CUSTOMER][NEUTRAL] I'm sorry, I am calling from SSM Health, and I wanted to check on a claim that we sent in and we got um an EOB back but.
[AGENT][NEUTRAL] Yeah, OK.
[CUSTOMER][NEUTRAL] Um, it doesn't explain about the whole bill.
[AGENT][NEUTRAL] OK. And can I get your name? Oh, yes.
[CUSTOMER][NEUTRAL] If that makes sense.
[CUSTOMER][NEUTRAL] My name is [PII].
[AGENT][NEUTRAL] Mhm. And can I get a good call back number in case we get disconnected?
[CUSTOMER][NEUTRAL] Uh huh [PII].
[AGENT][NEUTRAL] And do you have the policy number?
[CUSTOMER][NEUTRAL] 02141802
[AGENT][NEUTRAL] OK, one moment while I check on that for you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the patient's name and date of birth?
[CUSTOMER][NEUTRAL] [PII]. Date of birth [PII].
[AGENT][POSITIVE] OK, thank you so much for verifying that for me.
[CUSTOMER][POSITIVE] Mhm. You're welcome. Thank you.
[AGENT][NEUTRAL] Do you have the claim number or do we need to look it up by date of service? You have the claim number?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] No, I have the claim number. It's uh-huh 356-664-4.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 355-66644.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, just wanted to make sure.
[AGENT][NEUTRAL] It looks like we received that claim on [PII]. It was processed on.
[AGENT][NEUTRAL] [PII].
[AGENT][NEGATIVE] It looks like that was denied and let me see why.
[AGENT][NEUTRAL] It's like the benefits have been applied to the $1000 calendar year deductible is why it got denied.
[CUSTOMER][NEUTRAL] Yeah, and they all but they only applied 41865, so what about the remaining balance?
[AGENT][NEUTRAL] It looks like they might have already had something done where they used that deductible. Let me check real quick, OK?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And you said they were only charged how much?
[CUSTOMER][NEUTRAL] Um, well, the, the amount due after the primary insurance was $3,952 or I'm sorry, $4,371.04 and you guys only paid uh the patient's responsibility was 41865 cents and there's a balance left from you guys at 3,95239.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] One moment.
[AGENT][POSITIVE] I'm just gonna check something for you real quick.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me go ahead and check.
[AGENT][NEUTRAL] Just bear with me one moment while I search for that.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] What was the date of service?
[CUSTOMER][NEUTRAL] Uh [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Here we go.
[AGENT][NEUTRAL] And you said they were left with a bill of you said 418?
[CUSTOMER][NEUTRAL] No, 41865 was applied to the deductible, and there was a balance left at 3,95239. The primary insurance had applied 4,37104 to the uh deductible.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, OK, I see what you're saying.
[AGENT][NEUTRAL] It looks like some things on that were not covered, such as an office visit. Office visits are not covered under this policy, and so that's why the balance didn't apply to the claim.
[CUSTOMER][NEUTRAL] So this was a uh cardiology procedure.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh testing
[CUSTOMER][NEUTRAL] Is that considered an office visit?
[AGENT][NEUTRAL] Let me look at their policy and see exactly what they have because some policies have different.
[AGENT][NEUTRAL] Excuse me, definitions. So as for cardiology, were, were they seen in the, in the physician's office?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] No, this was a facility claim.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Give me one moment while I put you on hold so I can get that information for you, is that right?
[CUSTOMER][POSITIVE] All right, thank you. Yup, thank you.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Yeah, I, I can share my screen. She's on hold. She's saying that they were that we use, so it's claim number 3566644. I see a procedure code as facility. I thought that they had met their deductible, but she's saying that they were still getting charged.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] 356-664-4.
[AGENT][NEUTRAL] Oh, it was uh DM2M0360, and I read it to her.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah and she's saying that they still have um a charge and I I said that.
[AGENT][NEUTRAL] But she said that they only charged $418 and if the charge and if the deductible is a $1000 deductible.
[AGENT][NEGATIVE] She said if they only charged $418 to $1000 deductible, why is she still getting, why are they still getting, having to pay?
[AGENT][NEUTRAL] So I just say other procedures have charged to that deductible?
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] I have it on my screen.
[AGENT][NEUTRAL] Because my guess is that this $400 was it, and they've had other claims that met the deductible.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] We not share my screen, that might help.
[AGENT][NEUTRAL] Oh.
[AGENT][NEGATIVE] Oopsies. Well, it didn't help that I shared the wrong one.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] OK, it looks like the data service is 121-2025.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] I guess if I can get on this claim and double click.
[AGENT][NEUTRAL] What just happened.
[AGENT][NEUTRAL] Oh, OK, it pulled up on a different screen. OK, outpatient expense facility procedure and deductible.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] I have the EOB pulled up.
[AGENT][NEUTRAL] On my screen, yeah, I think I see oops.
[AGENT][NEUTRAL] It looks like before this charge, they were already they already had a deductible of $511 towards their deductible.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It said 1000 because it's outpatient mhm.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK. Oh, God.
[AGENT][NEGATIVE] The policy didn't pull through to.
[AGENT][NEUTRAL] 141842.
[AGENT][NEUTRAL] Oh, and then I look for the year [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] Claims for do I transfer her?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Healthy Alliance.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, can you, um, can you give me their number? I don't know where it is right this second. I all I see is the fax number where I'm at.
[AGENT][NEUTRAL] Oh, Quick connects.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] All right, thank you so much.
[AGENT][NEUTRAL] Alright, bye.
[AGENT][NEUTRAL] Are you still there, [PII]?
[CUSTOMER][NEUTRAL] Yes, yes.
[AGENT][NEUTRAL] OK. It looks like that might have gone through the 4:18 went through the major medical instead of through us. So if you don't mind, I'm going to um talk to our claim support, and then I will eventually transfer you over to them and we, they can figure out what all is going on.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Is that all right with you?
[CUSTOMER][POSITIVE] That works. Yup. Thank you so much.
[AGENT][POSITIVE] All right, give me, give me one moment. You're welcome.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Sorry.
[CUSTOMER][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How can I help you?
[AGENT][NEUTRAL] Hi, this is [PII] from APL care team. I have a [PII] on the line from SSM 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.
[CUSTOMER][NEUTRAL] Certainly, um, [PII], what's the policy number?
[AGENT][NEUTRAL] OK. The
[AGENT][NEUTRAL] 02
[AGENT][NEUTRAL] 14.
[AGENT][NEUTRAL] 1802.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the claim number?
[AGENT][NEUTRAL] Its 356-6.
[AGENT][NEUTRAL] 644.
[CUSTOMER][NEUTRAL] And it's for [PII], correct?
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] 356-664-4 OK.
[AGENT][NEUTRAL] And it looked like their major medical healthy Alliance.
[CUSTOMER][NEUTRAL] OK, let me pull up that mail number.
[AGENT][NEUTRAL] Looking at the documents that they have.
[CUSTOMER][NEUTRAL] Yeah, I'm gonna pull up the documents so just bear with me for one moment.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] It's taking just a minute to load.
[AGENT][NEUTRAL] Sorry, yeah.
[CUSTOMER][NEUTRAL] So it looks like they also have a a deductible on their meddling policy that they must satisfy before um.
[CUSTOMER][NEUTRAL] Let me just take a look here.
[AGENT][NEUTRAL] Yeah, and then when I looked.
[CUSTOMER][NEUTRAL] So it was applied
[CUSTOMER][NEUTRAL] 4 1865 from their major medical deductible.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That's, that's what it looked like to me, and then if I look in CLHBP it's not even showing that.
[AGENT][NEUTRAL] Because this is a um.
[AGENT][NEUTRAL] This is a cardiac.
[AGENT][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.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, it will
[AGENT][NEUTRAL] And she said there's like there's still a balance left of about $3000 if I could hurt her right?
[CUSTOMER][NEUTRAL] OK, so I'm pulling up her policy now, so just bear with me for one moment.
[AGENT][NEUTRAL] OK.
[CUSTOMER][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.
[CUSTOMER][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 meddling policy works. So the medling 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.
[AGENT][NEUTRAL] Under their medlink
[CUSTOMER][NEUTRAL] So if you look on let's see.
[AGENT][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.
[CUSTOMER][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.
[CUSTOMER][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?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I did, I did look at the PIBFT and then I even looked at the EOB.
[AGENT][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.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Cause it wasn't an office, was it?
[CUSTOMER][NEUTRAL] Certainly so um.
[CUSTOMER][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.
[CUSTOMER][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 meddling plan. So go ahead and give me, um, you said it was [PII] is her name?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] And what's the callback number just so I can reference it, [PII]?
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][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 then that's perfectly fine.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK, thank you so much. One moment.
[CUSTOMER][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 did not hear yes.
[AGENT][NEUTRAL] [PII], are you there?
[AGENT][NEUTRAL] 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, yes.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK, all right.
[CUSTOMER][NEUTRAL] OK, hi [PII], yes, 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] like love.
[CUSTOMER][NEUTRAL] OK, 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] 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.
[CUSTOMER][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?
[CUSTOMER][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.
[CUSTOMER][NEUTRAL] 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. 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 am I looking at the correct um.
[CUSTOMER][NEUTRAL] Am I looking at the correct date of service? I'm showing the charges were.
[CUSTOMER][NEUTRAL] 6428. However, the EOB only shows the um the code the MRI it looks like I believe it was 705-51 let me look at that.
[CUSTOMER][NEUTRAL] Do we have the right data service?
[CUSTOMER][NEUTRAL] Yes, 121 or 25.
[CUSTOMER][NEUTRAL] And it and it was for an outpatient MRI outpatient diagnostic, correct?
[CUSTOMER][NEUTRAL] Yes, but it, it was a cardiology um testing.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][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.
[CUSTOMER][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 charge from the primary.
[CUSTOMER][NEUTRAL] Are you, are you seeing the explanation of benefits from the primary insurance? Yeah, the one I'm received for this claim, the 356-664-4, I'm actually showing that um.
[CUSTOMER][NEGATIVE] Yeah, it's not the correct amount. That's why there's a discrepancy it looks like because this ELB 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.
[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.
[CUSTOMER][NEUTRAL] And you're saying the total charges are the 6428, right? 6,428, and what was 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?
[CUSTOMER][NEUTRAL] No, and that's what I'm saying this actual that you'll be this attached. It does say Health Alliance Life.
[CUSTOMER][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] 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 data server.
[CUSTOMER][NEUTRAL] OK, do you have a um.
[CUSTOMER][NEUTRAL] Uh, fax number I can send it to? 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 it'll be 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 877.
[CUSTOMER][NEUTRAL] 365.
[CUSTOMER][NEUTRAL] 94