AccountId: 011433970860
ContactId: 1d274700-8a63-41ad-912c-6afe25e07bb2
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 746840 ms
Total Talk Time (AGENT): 309400 ms
Total Talk Time (CUSTOMER): 261959 ms
Interruptions: 3
Overall Sentiment: AGENT=0.3, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/12/1d274700-8a63-41ad-912c-6afe25e07bb2_20250512T14:51_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII] calling from behalf of product office to check on a claim status.
[AGENT][POSITIVE] OK, well, I'll be more than happy to help you with the claim status, [PII]. And may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yeah, sure, [PII], just a second.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Just a minute.
[CUSTOMER][NEUTRAL] Yeah, you need my callback number, right?
[AGENT][NEUTRAL] Yes, the callback number and the policy number.
[CUSTOMER][NEUTRAL] Yeah, the callback number is [PII] with the extension [PII].
[CUSTOMER][NEUTRAL] And uh the member ID is.
[CUSTOMER][NEUTRAL] 02399312
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And [PII], how many claims do you have in total today?
[CUSTOMER][NEUTRAL] Yeah, I have only one thing.
[AGENT][NEUTRAL] OK, and can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yeah, sure. Just a second.
[CUSTOMER][NEUTRAL] Yeah. Mhm. Yeah. My name is
[CUSTOMER][NEUTRAL] Yeah, mama's name is uh [PII]. Date of birth [PII].
[CUSTOMER][NEUTRAL] You need a member ID?
[AGENT][NEUTRAL] Um, no, uh, you already gave it to me. I just need the data service and the total bills.
[CUSTOMER][NEUTRAL] Yeah, sure. For the date of service of uh [PII] with double the amount of $1,074.60.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Yeah, sure.
[AGENT][NEUTRAL] And can you um hold on one moment, verify the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] Yeah sure.
[CUSTOMER][NEUTRAL] Broadest office.
[CUSTOMER][NEUTRAL] Yeah, there was a dermatology Associate LLC.
[AGENT][NEUTRAL] OK, here we go.
[AGENT][NEUTRAL] Alright, so I'm showing the claim was received on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Claim number is 3,553,290.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And on [PII], the claim was denied requesting the explanation of benefits from primary insurance.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] You mean that I must you to need primary, right?
[AGENT][NEUTRAL] Yes, that's the denial reason, yes. So once we receive it, we can go ahead and continue processing.
[CUSTOMER][NEUTRAL] Uh, yeah, upon checking here, yeah.
[CUSTOMER][NEUTRAL] Yeah, upon checking here, you are the primary for this patient or
[AGENT][NEUTRAL] No, we
[CUSTOMER][NEUTRAL] Could you please provide when the COB was last updated?
[AGENT][NEUTRAL] OK, hold on one second. So we're not primary, we're secondary. This is a secondary policy. This policy has been active since [PII] and it's a secondary policy. The primary um insurance for this member is Aetna.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] And that's the explanation of benefits we're requesting.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, when the COB was lastly updated?
[AGENT][NEUTRAL] It was updated when the when the policy became effective. We're 2nd to Aetna. This is through their employer.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah, yeah. I'm just asking when it was uh COP was updated. The COB was updated on which date?
[AGENT][NEUTRAL] OK, so let me
[AGENT][NEUTRAL] So the date again is [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] [PII]. Uh, but upon checking here as our previous record, we received payment from, uh,
[CUSTOMER][NEUTRAL] Uh, APL insurance on for the data service [PII].
[AGENT][NEUTRAL] We're not denying the claim, saying that we won't pay it. We're just requesting the explanation of benefits so we can see primary and what was applied and then we can apply.
[CUSTOMER][POSITIVE] Yes, yes, yes.
[CUSTOMER][NEUTRAL] Yes, yes, that's correct. But upon checking here, as, as for our records, we can see uh for the date of service of [PII], we received payment from EP Insurance as primary.
[AGENT][NEUTRAL] You did not. You, we requested, we did pay out on the claim as secondary after you submitted the explanation of benefits.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] Yes, that's correct, yes.
[AGENT][NEUTRAL] It was denied initially?
[AGENT][NEUTRAL] OK, so we're 2nd.
[CUSTOMER][NEUTRAL] No, it, uh.
[AGENT][NEUTRAL] Sir, there's for this policy, we're secondary. We're 2nd to Aetna only.
[CUSTOMER][NEUTRAL] Yeah, you can see.
[AGENT][NEUTRAL] This policy is through their employer?
[CUSTOMER][NEUTRAL] Yeah, but how will the payment for that?
[CUSTOMER][NEUTRAL] Yeah, how will the payment for that uh data service as primary?
[AGENT][NEUTRAL] You did it.
[CUSTOMER][NEUTRAL] On [PII]. Yeah, on [PII], uh, [PII] data service. We submit the claim to you only as a primary and we receive payment from you as well.
[AGENT][NEUTRAL] Of $25 right?
[CUSTOMER][POSITIVE] Um, yes, that's correct.
[AGENT][MIXED] Correct, but when you submitted it initially it was denied.
[AGENT][NEUTRAL] Hold on one second.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So that claim number that you're referencing is claim number 3552666 and I'm pulling that up now so that I can let you know what we received, but this is a secondary, we're not a commercial, we're not primary for our company is not, but hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] Sure, sir.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] I'm just waiting for the documents to populate here.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] OK, so I'm seeing the claim form here.
[AGENT][NEUTRAL] And we paid out on the claim. This is a secondary policy.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] You mean for that [PII]im, you, you have processed a secondary?
[AGENT][NEUTRAL] Yes, American Public Life is not a major medical insurance company. We can't process this primary for anybody.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Unless it's a hospital indemnity policy, but this is a Medlink policy, which is a secondary supplemental gap insurance policy.
[CUSTOMER][NEUTRAL] Um, yeah, but how is the payment for that claim?
[AGENT][NEUTRAL] So this is what I'll do.
[CUSTOMER][NEUTRAL] The claim you process as.
[AGENT][NEUTRAL] Let me go ahead and get a claims examiner on the line so that they can discuss this further with you, um, and go into detail about the claim and why it was processed the way it was, um, but just for your records, this is a secondary policy and APL is not a major medical insurance company. Um, do you mind if I place you on just a brief hold while I get an examiner for you?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] You mean to send this claim back for the process?
[AGENT][NEUTRAL] No, I'm getting an examiner on the line with you now to discuss this claim and why the previous claim was um processed the way it was and that we are a secondary insurance company.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. Could you please, uh, uh, yeah, go ahead.
[AGENT][NEUTRAL] Sure, before I do that, was there anything else I could assist you with today?
[CUSTOMER][NEUTRAL] Um, no need.
[AGENT][NEUTRAL] OK, hold on one moment, OK?
[CUSTOMER][NEUTRAL] Yeah, OK.
[AGENT][POSITIVE] All right, thanks for calling APL.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] How about I mean.
[CUSTOMER][NEUTRAL] Ferring
[CUSTOMER][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hey [PII]. Oh, hey, [PII], this is [PII]. How are you?
[CUSTOMER][NEUTRAL] Fine, how are you?
[AGENT][NEUTRAL] I'm doing good. I feel like after the training now I could put faces to the names. Um, I have an insured, well, I'm sorry, I have a provider on the other line. Um, it's policy number 239.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 9312.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The rep, the um provider's name is [PII]. So he was calling originally for part two.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Claim number 3,553,290.
[AGENT][NEGATIVE] We denied it, requesting an explanation of benefits.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] But then he says, so why did you pay for [PII] as primary? And I said, well, we didn't, this is a secondary policy. So the, the claim he's referencing now is 3552666.
[AGENT][NEUTRAL] When I pulled up the documents and on base, there is no explanation of benefits, so maybe that's why he feels that way and we did pay out.
[CUSTOMER][NEUTRAL] So this is for the office visit for one night?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, this, yes, this is the, the office visit for outpatient. We don't need the EOB to pay that because it's the indemnity.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It's uh, on the rider, on the physician rider, it pays that limited benefit of $25.
[CUSTOMER][NEUTRAL] But as far as the outpatient benefits or inpatient, we have to have the EOB on those ones. But since this is just a physician, outpatient rider, we don't need the.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The explanation of benefits. OK, I'm gonna write that down. Um.
[CUSTOMER][NEUTRAL] You'll be.
[CUSTOMER][NEUTRAL] Mhm, yeah.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Can you talk to him? I mean, I can explain that, but he, with the rebuttals, in case he come back with something else.
[AGENT][NEUTRAL] Um, and he wants to talk to somebody else.
[CUSTOMER][NEUTRAL] Sure, I can explain that under the physician writer, um, the SY benefits are paid because it's just a writer under the plan, but the inpatient, outpatient, we will have, you'll be as required since we're secondary. I can explain it to him. You said his name is [PII]?
[AGENT][NEUTRAL] And just for uh and just for me, so this is for like Medli period if it's a like a like a writer like that.
[CUSTOMER][NEUTRAL] For this plan, for this coverage, for the MetLink 4, they have the outpatient physician writer. Now, however, under the other med links, um, like the newer medlings, cause this is the MetLin 4 and those was prior, we don't cause they have the, it's the physician writer, but the other ones like medling 5 and above, we have to have the EOP because it's either gonna be either for um specialist visit or primary care visit, yeah.
[AGENT][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Office, OK.
[AGENT][NEUTRAL] I got it.
[CUSTOMER][NEUTRAL] It pays differently for those benefits.
[AGENT][NEUTRAL] OK. Well, thank you for explaining that to me. Hold on one second, OK?
[CUSTOMER][POSITIVE] Mhm you're welcome.
[AGENT][NEUTRAL] Hello, [PII].
[CUSTOMER][NEUTRAL] Yeah, I'm here.
[AGENT][POSITIVE] Thank you so much for holding. I have [PII] on the line and she'll be assisting you further, OK?
[CUSTOMER][NEUTRAL] OK, hello [PII].
[CUSTOMER][NEUTRAL] Yeah, hi.