AccountId: 011433970860
ContactId: 3ac7facb-8562-4013-8cd7-430df4d3cfe3
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 689900 ms
Total Talk Time (AGENT): 293360 ms
Total Talk Time (CUSTOMER): 294469 ms
Interruptions: 1
Overall Sentiment: AGENT=0.3, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/13/3ac7facb-8562-4013-8cd7-430df4d3cfe3_20250213T19:10_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hey [PII], it's [PII] in Berker Resources. How are you?
[AGENT][POSITIVE] Hey [PII], I'm good. How are you doing?
[CUSTOMER][POSITIVE] Good.
[CUSTOMER][NEUTRAL] I have a couple of questions for you about some claims, um, I'll start with the one that I think is more simple.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, so I have a policy number, um, 019.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 893-89.
[CUSTOMER][NEUTRAL] Should be for a [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me look that up.
[CUSTOMER][NEUTRAL] And from what I understand in talking with the broker is that she already filed a claim but and again I never know if it's just that we asked for more information and they took it as a denial, but um.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] She's saying that she thinks she was told she didn't have any more funds available for reimbursement or claim payment.
[AGENT][NEUTRAL] OK, what is, what is the claim number and I can look and see what the remarks are on the claim.
[CUSTOMER][NEUTRAL] Um, it looks like it is 355-587-9.
[AGENT][NEUTRAL] OK that looks like it's the last one that was sent in let's see.
[AGENT][NEUTRAL] OK, so this is what um.
[AGENT][NEUTRAL] This is what the remarks say from the claims department.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It has a patient responsibility discrepancy.
[AGENT][NEUTRAL] And this is the everything that they said we are unable to determine the payable benefit amount, if any, based on the information submitted for this charge, there is a discrepancy which exists in the patient responsibility based on the allowed and provider paid amounts for this service as shown on the primary carrier's explanation of benefits or remittance statement.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] If there's a patient responsibility for this charge which was applied towards the primary carrier's deductible co-payment and or co-insurance, please resubmit this charge and include the primary carrier EOB which resolves the discrepancy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So, just to make sure I'm understanding it correctly, basically, we didn't receive anything that showed that she owed anything.
[AGENT][NEUTRAL] Yes, that's the way I'm reading it. And if the primary insurance did pay for deductible co-pay or coinsurance to submit the EOB stating showing that they paid.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] That's the way I'm reading it too.
[CUSTOMER][NEUTRAL] OK, I will pass that along that makes sense. um OK, the other one I think is a little bit trickier and it might be some things that I have to do on my end first, um, so to kind of describe the situation, um, we have a group, uh, group number is 26143.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And the the person that we're talking about specifically her name is [PII], and she has two different policy numbers in Lyon right now.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] And one of basically what happened, sorry go ahead.
[AGENT][NEUTRAL] Oh,
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] No, I'm listening.
[CUSTOMER][NEUTRAL] OK, um.
[CUSTOMER][NEUTRAL] One of her policies is lapsed, but it shows that it's paid through [PII] of this year and her other policy, like I think there's some issues about where maybe her payment was applied um and so I'm wondering she also filed a claim.
[CUSTOMER][NEUTRAL] And said that it was denied or there weren't funds available or they they kept using there weren't like she didn't have any more benefit amount available but I'm wondering if you can see something different on your end or if it's just that.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] I think that they've applied her premium payment to the wrong active policy.
[AGENT][NEUTRAL] OK, all right, so this sounds like.
[AGENT][NEUTRAL] I'm gonna look at the claim. Let's look at the claim together, but it sounds like we also need to touch base with customer service or uh or group billing actually because it's a group, so we'll need to touch base with group billing so that they can get the corrections made on the policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] If there was anything that was applied wrong.
[CUSTOMER][NEUTRAL] OK, I do not have a claim or a um yeah claim number for this one, so I don't know if she's filed multiple claims or if there's just the most recent one so I don't I don't have anything specific on her just her name.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. And it's [PII]. Let me look in um GRP IQ let's see if I can find her.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And it's group 2643.
[CUSTOMER][POSITIVE] Yes, correct.
[AGENT][NEUTRAL] OK, her policy number I'm showing that's active 259-568-0.
[AGENT][NEUTRAL] Let me write that down and then.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me pull her up.
[AGENT][NEUTRAL] OK, let me see if she has any claims on this policy number.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] A recent
[AGENT][NEUTRAL] OK, there are no claims on the active policy, so let's look at the other one.
[CUSTOMER][NEUTRAL] OK, OK, I do have her last policy number if you want that.
[AGENT][NEUTRAL] I've got it. It pulled up in CUI and Q when I pulled in the other policy. Thank you though.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, let's see what we got going on on the laps one.
[AGENT][NEUTRAL] OK, looks like on.
[AGENT][NEUTRAL] Do you have the date of service?
[CUSTOMER][NEUTRAL] I don't. Well, I wanna say it was like.
[AGENT][NEUTRAL] OK, that's OK.
[CUSTOMER][NEUTRAL] [PII] maybe?
[AGENT][NEUTRAL] Yeah, because she only has three claims that she's filed on the see. One of them was paid on [PII].
[AGENT][NEUTRAL] Let's see if that's going to be.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Centra RMH Medical Center.
[AGENT][NEUTRAL] Let's pay $2000 with check number 2017325 and that was where a service was.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK, what did you say the amount was?
[AGENT][NEUTRAL] And then let's look at the
[AGENT][NEUTRAL] 2000
[CUSTOMER][NEUTRAL] I'm sorry, it cut out on me. Are you, did you say 2000?
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] OK, well then that probably would explain any future claims that were denied if they were if they fell in December because her plan amount was only 2000.
[AGENT][NEUTRAL] Yeah, let me look at the rest of the claims though and just see what the remarks are.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] And they both have the same remarks, so it's gonna be the same thing. Let's look.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Oh, outpatient benefit for this calendar that so that's correct. The $2000 paid for the service for [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, with that check number I gave you.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] To the let's see, was it paid to the facility or was it paid to her?
[AGENT][NEUTRAL] Let me look real quick. I'm gonna pull up the check.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 2017325.
[AGENT][NEUTRAL] Let's look up the check number 2017325.
[AGENT][POSITIVE] Yeah it was paid to the facility and it did clear.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, well that does help on that issue and I will do some like work on my end and talk with billing and see what I can figure out about her.
[CUSTOMER][NEUTRAL] Two policies and where some of those payments might have been applied so.
[AGENT][NEUTRAL] Now looking at her policies, the first one that was lapsed, the 245-8649, looking at it.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] It was effective from [PII] to.
[AGENT][NEUTRAL] [PII] and then a new policy was issued on.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yeah, so they're the groups, um, the group renews on [PII] and from what I understand with talking with the broker is that when their plan renewed on [PII], um, she moved to the higher plan option of $3000 a year instead of $2000.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So I think that's obviously why she has the two policies, but I believe that payment premium payment must have been posted to the um the lapsed account because she shouldn't be paid to 3125 on that old policy that's lapsed, um.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] But either way there was confusion because their renewal date, renewal date is [PII], but the calendar year starts over in January. So I think in her mind she was thinking, oh well, you know, the new plan started in December, so I should get that benefit, but it doesn't start again until January.
[AGENT][NEUTRAL] OK. Yeah.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] No, and it actually by the data service which was in November.
[CUSTOMER][NEUTRAL] Yeah, OK.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] OK. Well, that helps a lot. I appreciate it very much.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] It's no problem at all. I hope you have a good rest of your day, Ms. [PII].
[CUSTOMER][POSITIVE] Yeah, thanks you too.
[AGENT][POSITIVE] Alrighty bye bye.
[CUSTOMER][NEUTRAL] OK. Bye.