AccountId: 011433970860
ContactId: 15b11083-2186-4d68-a414-d63819218665
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 771080 ms
Total Talk Time (AGENT): 392122 ms
Total Talk Time (CUSTOMER): 370228 ms
Interruptions: 5
Overall Sentiment: AGENT=0.4, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/24/15b11083-2186-4d68-a414-d63819218665_20250324T18:38_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How can I help you?
[CUSTOMER][NEUTRAL] Yes, um, I really can't hear you.
[AGENT][NEUTRAL] Uh, I'm sorry, let me see if I can turn up my microphone.
[CUSTOMER][NEUTRAL] OK, yeah, I can hear you now. I can hear you now.
[AGENT][POSITIVE] You can. OK. Oh good. OK. How can I help you?
[CUSTOMER][NEUTRAL] Yes, my name is [PII]. My name is [PII]. Yes, my name is [PII] calling from the business office of Newberry returning your call about a Chapman.
[AGENT][NEUTRAL] Yes, let me get that information pulled up here, bear with me for just one moment.
[CUSTOMER][NEUTRAL] OK, it's.
[CUSTOMER][NEUTRAL] I you.
[AGENT][NEUTRAL] OK, and.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] OK, so I guess there was some confusion in regards to the claims that were received. Uh, looks like it was an emergency room for data service 216-2025. Is that right?
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Can you, yeah, do me a favor, can you spell um the first name again?
[AGENT][NEUTRAL] My first name?
[CUSTOMER][NEUTRAL] No, his, his first name.
[AGENT][NEUTRAL] Oh, I'm sorry. er [PII] I think it is.
[CUSTOMER][NEUTRAL] OK, I have it
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, yeah
[CUSTOMER][NEUTRAL] OK, alrighty, so what happens is looking like.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I had talked to [PII] and she's according to her she believed they built the tax ID claims all to get oh yeah something about the they processed the claim, but it's really should have been two claims.
[CUSTOMER][NEUTRAL] I don't know the remit we have has the.
[AGENT][POSITIVE] Correct, and there was.
[CUSTOMER][NEUTRAL] Uh huh go ahead.
[AGENT][NEUTRAL] I was gonna say there were 2 claims. I'm not sure why she uh stated it was the same claim. It is the same services, but there were 2 separate claims.
[CUSTOMER][NEUTRAL] Exactly, we know we have two separate claims and so what we were trying to do is they we were telling them they need to be split because we, we do two different billings. They have their own billing department and we have our own billing department so by them being on the same claim.
[CUSTOMER][NEUTRAL] Um, they don't, they're not getting theirs. They need their portion of this claim as well, and it doesn't look like a payment was made on it. Is that correct?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so let me just verify.
[CUSTOMER][NEUTRAL] Uh, looks like $10 for.
[AGENT][NEUTRAL] Yeah, can I verify which claim you're uh referring to? I did receive two separate claims. One was a professional fee and one was the facility fee.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh, exactly, mhm, and we're the larger fee. I'm just trying to pull up the remit right now because that $10 I believe should go with the professional part.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Um, not the, OK, so not the way that, first of all, that, that not the way this policy works, and secondly, um, the facility, um, claim, which is the Newberry County Memorial Hospital, and those charges were, I think a total of 103,720. Is that right?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Yes, mhm, mhm.
[AGENT][NEUTRAL] OK, OK, and this is the claim, uh, claim number is 357-435-0?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Wait a minute. Let me, wait, yeah, I'm, I'm, give me a minute. I wanna pull up the remit because I wanna look at it while we're talking because um.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Sure.
[AGENT][POSITIVE] Absolutely.
[CUSTOMER][NEUTRAL] Oh here we go. OK, it was a little confusing. I'm like, OK, $10 belonged to who? Uh, I see the remit. OK, now I have it. OK, yeah, I see it. So it's $10 on the.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Um, that's another thing. I don't even, it doesn't even have like a total, total charge on it.
[CUSTOMER][NEUTRAL] Uh, I mean the, the remit just has $10 noncover charge for ER, but it's not even a total charge even if they're not gonna pay on it. They're not telling me which claim is which.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, so I can kind of explain it a little bit based on this policy, [PII].
[CUSTOMER][NEUTRAL] So let me see.
[CUSTOMER][NEUTRAL] OK, yeah.
[AGENT][NEUTRAL] So this policy, it, it, it is a limited medical hospital indemnity plan. So it does have limited medical benefits. Now, this particular, um, this particular policy, it has an outpatient sickness benefit rider. And what that means is that the diagnosis has to be a sickness or illness or the, or the charge is not payable based on the diagnosis, it looks like it was reported as an accident.
[CUSTOMER][POSITIVE] Alright, let's I'll pull it up.
[CUSTOMER][NEUTRAL] OK OK mhm.
[CUSTOMER][NEUTRAL] Understand
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So, um,
[CUSTOMER][NEUTRAL] Uh, well, yeah, it looks like the patient, it was the accident, the the patient cut her hand in the kitchen. So that was the accident, OK.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] OK, so that diagnosis isn't payable for the emergency room charge, so we deny that emergency room charge, but because there was a laceration repair, we consider that under their surgical uh benefit rider, and that was that the uh CPT code 12001. It was a $469 charge.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, see that's not, that's not our test. Let me look at the claim and then we don't say it's not our charge. OK, yeah, OK, the $469 charge, OK.
[AGENT][NEUTRAL] OK, so we paid a $10 right, that's correct for the sur for that's the surgical benefit under that uh repair for laceration.
[CUSTOMER][NEUTRAL] So you paid $10 on the repair.
[CUSTOMER][NEUTRAL] OK, alright, so I'll probably pay $10 on repair.
[AGENT][NEUTRAL] So this was the facility, right, this was the facility, uh, charges, so we paid the benefit on that like I said under that uh surgery rider we paid that $10 benefit to the facility, um, and then on the pro on the professional component of the same data service that was a separate claim.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And that claim was denied due to the only it's a professional fee and again that diagnosis indicates it was an accident, so we denied it again under that uh accident not covered and then we also denied the laceration as max maximum benefit meant for the date of service, meaning that we paid the facility uh that $10 benefit under that uh la for that laceration.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] And then under the professional component, it was denied as max benefit.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, OK, so, um, OK, for some reason I don't know why they put these like.
[CUSTOMER][NEUTRAL] Uh, OK, so that, OK, that's one in limited benefits because the patient has another insurance too has another kind of insurance which probably is the same thing. I was just trying to call you all back, but because it looks like the two they have on there really should be one.
[AGENT][NEUTRAL] And, and we.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] You know what I'm saying, because the ID number.
[CUSTOMER][NEUTRAL] That we see for the APL it's the same thing for IMA.
[AGENT][NEUTRAL] Correct, and it actually that's one and the same. So how it works is that that patients benefit so the claims do go to IMA, which is the benefits in a card. The claims go to IMA and then I IMA forwards them to us for processing to next to go under any of the benefits that may be payable under their limited medical hospital indemnity, which is what happens.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Hi.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And payment.
[CUSTOMER][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] And and then the facility claim we received that one first so that was processed first because we were we we do once they're received and they're received in day order and even if it's the same date if that one was indexed like I said we we process them as they come in so that facility fee um for for your claim um we pay the benefit that was payable and then like I said that professional fee was received after the fact so that one was denied as maximum meant.
[CUSTOMER][POSITIVE] Alrighty.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh huh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and so that, that, that'll go to them. They'll get back that one there maximum that the actual, the actual phys physicians practice will get that that you're talking about, right?
[AGENT][NEUTRAL] Uh, well, no, it was issued to the, to the hospital.
[AGENT][NEUTRAL] The facility claim the UBO4.
[CUSTOMER][NEUTRAL] OK, so you have you.
[CUSTOMER][NEUTRAL] Right, but
[CUSTOMER][NEUTRAL] OK, so have you got the 1500 yet for this same date of service? That's what I was asking because you should get another claim from them, the actual physician, they have their own billing department. OK, I just wanted to make sure.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] And so you know what you just explained to us we have no idea of it being a limited benefit so that was the reason why I was calling because it just did not make sense to me for the $10 but now that you told me what it doesn't have a procedure code or nothing like that. So when you told me that I was able to look at the claim and see the $469 that you did pay $10 off, but explain it to me, I can put it in my notes because the rest of this is the patient's responsibility.
[AGENT][NEUTRAL] Right, right.
[CUSTOMER][NEUTRAL] Because it's a limited benefit, um.
[AGENT][POSITIVE] Correct. Now.
[CUSTOMER][NEUTRAL] This is a limited benefit policy.
[AGENT][NEUTRAL] Right, and now I do see they actually, um, Simone, they do actually have an accident only policy with us as well, and both of those claims, not to confuse you even further, but both of those claims were received and again it's the facility fee and the professional fee and it does look like they, they were issued a check under the professional fee under that accident policy and they were paid a benefit as well for that policy.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so are you saying that this one here is being processed to under another policy?
[AGENT][NEUTRAL] Well it has been already, yes.
[AGENT][NEUTRAL] And you would have
[CUSTOMER][NEGATIVE] OK, I'm just saying before I pass this to the patient's responsibility, I just didn't wanna think something the patient has another policy out there that's gonna pay something.
[AGENT][NEUTRAL] Yes, like I said they do let me pull that up again, just bear with me.
[AGENT][NEUTRAL] There was, it looks like an additional $500. So do you see that has been received or no?
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So should I.
[CUSTOMER][NEUTRAL] Wait to see if it's gonna they're gonna process it under that other part of the policy to give us $500.
[AGENT][POSITIVE] Well, like I said, it looks like that benefit was actually processed to the uh professional fee.
[CUSTOMER][NEUTRAL] To the professional fee.
[AGENT][NEUTRAL] Yeah, the doctor's charges. So the 10:37 20, the UBO4, yes, uh-huh.
[CUSTOMER][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] Oh, to the doctor's charge.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the reason being is.
[CUSTOMER][NEUTRAL] OK, the UBL4 is already completed mhm.
[AGENT][NEUTRAL] Yes, that's correct. The UBO4 was, was, um, already processed under that accident only as well.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][MIXED] Then only OK.
[AGENT][NEUTRAL] And then of course it was denied as as the maximum benefit met because the the benefit was paid to the professional fee under that additional claim for that same data service. So as far as the facility fee, which I believe is your claim on the UBO4, that's the maximum that's gonna be paid is that $10. So then um you would go ahead and, and, uh, take care of that balance however you need to on your side.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Is it mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The the patient.
[CUSTOMER][NEUTRAL] OK, great, uh thank you for explaining it because I'm like this is not making sense. OK, alrighty, so I just wanna make sure I got enough for my and your name is?
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] It's [PII]
[CUSTOMER][NEUTRAL] OK, [PII], um, do you have a reference number?
[AGENT][NEUTRAL] My my last initial would be L like love, so my name and today's date is your uh call reference number.
[CUSTOMER][NEUTRAL] No, OK.
[CUSTOMER][NEUTRAL] Yeah, OK.
[CUSTOMER][POSITIVE] Call reference. OK, great. Well thank you so much for explaining that and I'll make the um adjustments that I need to this claim but you um thanks for calling calling us back to explain that you have a great day.
[AGENT][POSITIVE] You too, [PII], thank you so much I hope you have a great day as well.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Bye bye.
[CUSTOMER][NEUTRAL] You too bye bye.