AccountId: 011433970860
ContactId: 37cb7c2d-bc76-4835-a44e-3c1a336d98e3
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1203939 ms
Total Talk Time (AGENT): 572889 ms
Total Talk Time (CUSTOMER): 334231 ms
Interruptions: 16
Overall Sentiment: AGENT=0.1, CUSTOMER=-1.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/18/37cb7c2d-bc76-4835-a44e-3c1a336d98e3_20250618T18:35_UTC.wav
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[AGENT][NEUTRAL] Calling APL, this is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Uh, yes, I was calling on a patient's benefits or a claim payment.
[AGENT][NEUTRAL] I have your name and a callback number, so you're calling to check the status of a claim.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Well, I have a claim payment that we received, but I had a question about how you all processed it.
[AGENT][NEUTRAL] The status of a claim. So could I have your call back number, [PII]?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII], what is the policy number of the member that you're calling to in regards to the claim?
[CUSTOMER][NEUTRAL] The claim the policy number is 01677928.
[AGENT][NEUTRAL] What is this member's name and date of birth?
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][NEUTRAL] And what is your claim number?
[CUSTOMER][NEUTRAL] The claim number is 3609841.
[AGENT][NEUTRAL] So you're calling in regards to the claim and it looks like the office visit of the procedure code of 99214 is not covered under the policy.
[CUSTOMER][NEUTRAL] Right, so the patient, so the patient has two Blue Cross plans. You guys are her tertiary. Do you show that?
[AGENT][NEUTRAL] We're just a gap insurance.
[CUSTOMER][NEUTRAL] Because it looks like
[CUSTOMER][NEUTRAL] OK, so the gap and so the patient has the first Blue Cross plan.
[CUSTOMER][NEUTRAL] Put $173.78 towards the member's deductible, which is what you guys paid. I'm assuming that's what the gap is.
[AGENT][NEUTRAL] Mhm. Right. Mhm.
[CUSTOMER][NEUTRAL] But she has a second Blue Cross that paid the 173.78 so now she has her credit because your payment we didn't need because her secondary covered. Does that make sense?
[AGENT][NEUTRAL] It actually does make sense. However, this is a gap insurance, so it went towards the deductible copay and co-insurance even if another insurance policy insurance company did make a payment, so that means that you just give that.
[CUSTOMER][NEUTRAL] So we just
[AGENT][POSITIVE] Yes, make a check out to the member.
[CUSTOMER][NEUTRAL] OK, so we'll just have a credit.
[AGENT][NEUTRAL] Or if she wants her money to be credited to her account.
[CUSTOMER][NEUTRAL] The patient
[CUSTOMER][NEGATIVE] Well, I mean the payment was made to us. I don't, that's what I'm not understanding how all of this works because usually when there's a credit it goes back to the person that gave us the money.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] I.
[AGENT][NEUTRAL] Um, because this is a.
[CUSTOMER][NEUTRAL] But I, I don't, I'm guessing you guys aren't getting the second Blue Cross explanation of benefits or you would know that they already paid it.
[AGENT][NEUTRAL] So which
[AGENT][NEUTRAL] No, we don't, we wouldn't go by that. We will go by hers, her, like, so [PII] is the, the policyholder here, and in order for her to have two policies, that means that she has a policy and probably her spouse is these um.
[AGENT][NEUTRAL] Policyholder for a 2nd 1?
[CUSTOMER][NEUTRAL] OK, so how, so who sends you the information because I don't think I sent you a claim, so I don't know if Blue Cross forwards it to you or does the patient send it to you? I'm just not familiar with these type of plans. I'm sorry.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] It doesn't cross over so someone from your facility had to send it over to us.
[AGENT][NEUTRAL] Bear with me while I pull up the policy, the claim itself.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, you're fine.
[AGENT][NEUTRAL] Who process this client.
[CUSTOMER][NEUTRAL] It looks like both of them are through for Walmart.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] I want the deductible.
[AGENT][NEUTRAL] Who is the policy for 9458?
[AGENT][NEUTRAL] 9458.
[AGENT][NEUTRAL] And then there's another one.
[AGENT][NEUTRAL] Who's the policy holder for this one?
[AGENT][NEUTRAL] These are two different policy numbers, so one of them has to belong. Does she have two medical policies?
[AGENT][NEUTRAL] But that'll be impossible unless she has two jobs.
[CUSTOMER][NEUTRAL] Right, like, how does that, I guess she works.
[CUSTOMER][NEUTRAL] Yeah, she works 2 full-time jobs and then she has a gap.
[AGENT][NEUTRAL] Yeah, let's let me see who's the employer for this one.
[CUSTOMER][NEUTRAL] A gap plan
[CUSTOMER][NEUTRAL] Uh, one is the municipal Hospital Authority and one is Walmart.
[AGENT][NEUTRAL] No I'm saying, let me see who's the employer for the um the gap insurance. So it's the school district. So we will go by, so we went by the one from the school district.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Oh my bad, OK.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] So which one is.
[AGENT][NEUTRAL] So which one is the um.
[AGENT][NEUTRAL] Employers
[AGENT][NEUTRAL] What's the employer.
[AGENT][NEUTRAL] Do it show which policy numbers for Walmart, I mean for the school district?
[CUSTOMER][NEUTRAL] At the YUP 823-889-458 is the well that's for the Lindsay Municipal Hospital that's the Lindsay Municipal Hospital, OK.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] And see where the gap insurance to that one.
[AGENT][NEUTRAL] Mhm, that's the one.
[AGENT][NEUTRAL] That's what she, that's the primary, so that's, that's who she has a gap insurance with.
[AGENT][NEUTRAL] And we will pay towards, but I don't know why they wouldn't have, I guess because you guys submitted the claim and assignment of benefits, so assignment of benefits automatically goes to the provider.
[AGENT][NEUTRAL] But you can, we didn't, we didn't process it in error but you can send a um.
[CUSTOMER][NEUTRAL] Yeah, but
[AGENT][NEUTRAL] A check back explaining that you're sending a refund because her secondary paid the full balance.
[AGENT][NEUTRAL] May I place you on a brief hold if you don't mind? Let me make sure because.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah, and if you're looking into it further, it's also applies to her first data service with the if you need that. I don't know if you need that or not.
[AGENT][NEUTRAL] What is the first date of service?
[CUSTOMER][NEUTRAL] Um, the same thing happened on her [PII] data service.
[AGENT][NEUTRAL] Of [PII].
[CUSTOMER][NEUTRAL] Everybody paid.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK. I'm gonna place you on a brief hold, [PII] and I'll be right back.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] Hey, [PII], how are you doing?
[AGENT][POSITIVE] Oh, I could be better. Today has been a crazy day. It feel like a Monday instead of a Wednesday today.
[AGENT][POSITIVE] I won't complain cause it's almost over for me.
[AGENT][NEUTRAL] I'm calling because I have a provider on the phone.
[AGENT][NEUTRAL] And um she's calling about a claim under a policy. The member has [PII], she has two major medical insurances. However, I did explain to her that the, the gap insurance will only go towards the.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Whatever employer she got the gap insurance with matching the same.
[AGENT][NEUTRAL] Right, so the major medical was the 170 let me the policy number so you can look at it.
[AGENT][NEUTRAL] Um, the policy number is 1677928.
[AGENT][NEUTRAL] For [PII].
[AGENT][NEUTRAL] And the the claim number is 3609841. So what we, so what the providers calling about is she wanna know what do they do with the check that we sent them because.
[AGENT][NEUTRAL] The primary, which is the primary, the, the gap insurance actually go to says that it's $173.78 under the deduct. However, the second EOB shows that.
[AGENT][NEUTRAL] It paid the full balance and there was nothing due so I explained to her that we will process based on the primary EB.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Well, actually, so $75 to know after the made to pay.
[AGENT][NEUTRAL] Mhm. The primary of this number is page 3.
[AGENT][NEUTRAL] Right, but it's one of them, the first one is with um.
[AGENT][NEUTRAL] The hospital that she has a gap insurance with, the one ending in 9458.
[AGENT][NEUTRAL] On page 3.
[AGENT][NEUTRAL] And then the second one is through Walmart.
[AGENT][NEUTRAL] No, no, she got two full-time jobs on this one of these is her insurances and then the other one is spouse insurance.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] But it's two different
[AGENT][NEUTRAL] Member IDs.
[AGENT][NEUTRAL] The hospital, the um provider said that the one ending in 9458, the policy number for Blue Cross 9458 is the one for the hospital, which is the one that we have here that's the group who's got the gap is showing with then the second one on page 4 is for through Walmart.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEGATIVE] We made a payment, but there was no payment due, she said, but there's, it looks like $75 was due on the second one on page 4 still was a balance of $75 on the deductible.
[AGENT][NEUTRAL] Mhm. She verified, she said that um
[AGENT][NEUTRAL] The first one on page 3 is for the Lincoln Hospital and then the second one on page 4 is for Walmart.
[AGENT][NEUTRAL] Employers Walmart. The group is a Walmart.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So,
[AGENT][NEUTRAL] Right, so she said that now is a credit on their on their account. What do they supposed to do with it? Do they send it back to American Public Life and I told her no because we processed it correctly and she could send it back as a refund if that's what she wanna do explaining why the reason for the refund.
[AGENT][NEGATIVE] And then she was like, well, I said, or just give the money back to the insured. She was like, well, we can't give the insured money that somebody paid us.
[AGENT][NEUTRAL] I was like, well, that was her, we're her 2nd year.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] I let her know.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you.
[AGENT][POSITIVE] Have a good day.
[AGENT][NEUTRAL] Uh
[AGENT][POSITIVE] Thank you for holding. I apologize for the inconvenience. So, because the pol this is her.
[CUSTOMER][NEUTRAL] You're fine.
[AGENT][NEUTRAL] This policy goes with her Lincoln Hospital primary insurance policy and will be considered as secondary.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] And then her other Blue Cross, even though they think they're secondary, so there's just a big credit on the account then.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mm, well, majority.
[CUSTOMER][NEUTRAL] Until she gets her coordination of benefits corrected.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Because the YUP is the showing their primary.
[AGENT][NEGATIVE] I don't, I don't, I won't be able to answer that.
[CUSTOMER][NEUTRAL] The Walmart is showing their secondary and they're paying according to the fact that they understand that.
[AGENT][NEUTRAL] Well, actually, Walmart only pay, if she has a balance under the Walmart, it'll be of $75.
[CUSTOMER][NEUTRAL] So you all.
[AGENT][NEUTRAL] Under her deductible line.
[CUSTOMER][NEUTRAL] Right, but that's still, and you guys paid $173.78 so which was the deductible, so that would.
[AGENT][NEUTRAL] Mhm, cause that's the primary insurance.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] But that would still leave a almost a $100 credit.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] To someone
[AGENT][NEUTRAL] Yeah, I mean, when my stuff is crazy, they just send me out a check.
[CUSTOMER][NEUTRAL] Because it was 17378.
[AGENT][NEUTRAL] Is it from the doctor's office when I have credit on my account from the doctor's office, they call me and ask me if I wanted to be credited to my account for future visits or would I like a payment in check, so.
[CUSTOMER][NEUTRAL] Hm?
[AGENT][NEUTRAL] But
[CUSTOMER][NEGATIVE] But she didn't pay it. The insurance companies paid it.
[AGENT][NEUTRAL] Mhm. So you can.
[CUSTOMER][NEUTRAL] If she had paid it, it would be, it would go to the patient.
[AGENT][NEUTRAL] You can send it back explaining that you're sending a refund back because the.
[AGENT][NEUTRAL] And the reason why, but we didn't process it in error.
[CUSTOMER][NEUTRAL] Because they're secondary took care of it.
[AGENT][POSITIVE] Yeah, we processed it correctly.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK, I will make a note on the account.
[AGENT][NEUTRAL] And that's for the [PII] as well, the same reason.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] OK, thanks for your help.
[AGENT][NEUTRAL] But I can't believe that the insurance company, they never want to pay anything, so they normally would give you the run around like, oh this member has this member has a different po another policy. Yeah, they'd be like, this member has another carrier, so.
[CUSTOMER][NEUTRAL] I know I've never had 3 insurance. I've never had 3 insurance companies pay.
[CUSTOMER][NEUTRAL] Yeah, cause the first one.
[CUSTOMER][NEUTRAL] Right, and obviously you all didn't know about the other Blue Cross because if you did, you wouldn't have paid the 173 78 deductible.
[AGENT][NEUTRAL] No, we still would have paid it because she has a um.
[CUSTOMER][NEUTRAL] Because the second
[AGENT][NEUTRAL] We still would have went by because the gap insurance that she has is attached to the primary Blue Cross.
[AGENT][NEUTRAL] If that makes sense. Well, or maybe you just probably need to verify if that's a spouse.
[CUSTOMER][NEUTRAL] So do I need to, do I need to.
[AGENT][NEUTRAL] The second one with Walmart is hers.
[CUSTOMER][NEUTRAL] No, it's her on both of them.
[AGENT][NEUTRAL] That one hers is hers too?
[CUSTOMER][NEUTRAL] Yeah, I just checked the benefits on availity yeah.
[AGENT][NEUTRAL] Oh.
[AGENT][POSITIVE] She's a good one working at the hospital in Walmart.
[CUSTOMER][NEUTRAL] So if that's the case then the 2nd Blue Cross would get a deductible. I know, right? Most people can't get one decent insurance plan and she has 3 almost.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Yes.
[AGENT][MIXED] It's good, but I can't believe you.
[CUSTOMER][NEGATIVE] Well it's an accounting nightmare on my end for sure.
[AGENT][NEGATIVE] I know it is, but um you could send the check back and, you know, say that it was, you think that it's an error and you think that there should be a refund.
[CUSTOMER][NEUTRAL] But you
[AGENT][NEUTRAL] But we didn't make the error, we paid it correctly.
[CUSTOMER][NEUTRAL] Yeah, I mean you were saying that.
[CUSTOMER][NEUTRAL] Right, based off of her primary, you covered the deductible amount.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And then her secondary did it completely different. They allowed different amounts on each one of them and only put $75 to deductible, so that way by the time I got your payment, there's like a $100 credit.
[AGENT][NEUTRAL] Right.
[AGENT][NEGATIVE] Mm, sounds like it's a headache. Mhm. Because this, cause this gap insurance goes with her primary insurance. I know it's crazy that I'm saying it like they would.
[CUSTOMER][NEUTRAL] But you're saying you would have paid it regardless.
[CUSTOMER][NEGATIVE] It is a headache, so.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] It goes with her primary insurance.
[CUSTOMER][NEGATIVE] I know then it almost makes me think that I need to refund her secondary.
[CUSTOMER][NEUTRAL] Because you were saying you would have paid anyway.
[AGENT][NEUTRAL] Probably do.
[AGENT][NEUTRAL] Yeah, but we would have paid anyway.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So, it um.
[CUSTOMER][NEUTRAL] Right, so that means that her secondary would.
[CUSTOMER][NEUTRAL] I don't, I'm able to call Blue Cross and see what.
[AGENT][NEGATIVE] I can't believe that they made a payment because.
[AGENT][NEUTRAL] Normally when you have multiple insurance companies, they plant hot potato with the claim, but
[AGENT][NEGATIVE] They both hate them.
[CUSTOMER][NEUTRAL] Well, oh, I know. Yeah, they both, yeah, well, the one really didn't because they put it towards her deductible and everything they put towards her deductible on the first one, the second one paid and put the other stuff towards her deductible, so they canceled each other out.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Yep, and then you guys came in and paid extra so OK.
[AGENT][NEUTRAL] Well, look, I wish I could call you back and see what was the outcome of that, [PII].
[CUSTOMER][NEUTRAL] Well
[CUSTOMER][NEUTRAL] I know. I don't, yeah, I'm not sure what I'm gonna do at this point. I'm just trying to get it straight on the account and it may just show a credit because I have a feeling one of the blues is gonna, well, Blue Cross is notorious for finding the, yep, yep, so I'm just gonna kind of let it all sit for a minute.
[AGENT][NEUTRAL] Because
[AGENT][NEUTRAL] I really want to know.
[AGENT][NEUTRAL] You requesting a refund?
[AGENT][NEUTRAL] Next year, little later on next year. Next year.
[CUSTOMER][NEUTRAL] Oh yeah, or 2 or 2 or 3 years down the road they'll ask for a refund and then you've got to figure it all out again from scratch so I'll probably just make notes on the account.
[AGENT][NEUTRAL] All righty, well,
[CUSTOMER][NEUTRAL] And um wait for Blue Cross and Blue Shield for about a couple of months and see what they do and then reassess the damage.
[AGENT][NEUTRAL] Is there anything else that I can assist you with today?
[CUSTOMER][POSITIVE] No, that's all thanks for your help.
[AGENT][POSITIVE] You're welcome thanks for calling APL and have a great day.
[CUSTOMER][NEUTRAL] OK, um
[CUSTOMER][NEUTRAL] You too bye.