AccountId: 011433970860
ContactId: 40015767-29f2-42cc-9b80-16da0eeeaef8
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 350799 ms
Total Talk Time (AGENT): 157927 ms
Total Talk Time (CUSTOMER): 103481 ms
Interruptions: 1
Overall Sentiment: AGENT=0.6, CUSTOMER=-0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/14/40015767-29f2-42cc-9b80-16da0eeeaef8_20250114T19:35_UTC.wav
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[AGENT][NEUTRAL] Calling APL, this is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Good morning, [PII]. My name is [PII] with USC Arcadia Hospital. I need to get status on a claim, please.
[AGENT][NEUTRAL] OK, [PII], I can help you with claim status and in case this call is disconnected, may I have your callback number?
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Sure, it's [PII] area code [PII].
[AGENT][NEUTRAL] Thank you. And may I have the patient's policy number, please?
[CUSTOMER][NEUTRAL] That is 02262644.
[CUSTOMER][NEUTRAL] M as in Mary, L as in Larry, 8.
[AGENT][NEUTRAL] Thank you, and that was 02262644 ML 8?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And may I have the patient's name and date of birth, please?
[CUSTOMER][NEUTRAL] [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] Thank you. And what is the date of service and the bill amount of the claim?
[CUSTOMER][NEUTRAL] Data service is.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 1127 23 for $314.
[AGENT][NEUTRAL] Thank you, that's for data service, 1127 $23 for $314.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] So I sure you received that claim back on [PII]. It was processed on [PII]. Nothing was paid on this claim because benefits are only payable, benefits are only payable if major medical insurance provider provides benefits. I don't show from the EOB that we have that anything was applied towards their deductible, co-pay or co-insurance where they're secondary, so we pick up their deductible co-pay co-insurance.
[CUSTOMER][NEUTRAL] that
[CUSTOMER][NEUTRAL] Make
[AGENT][NEUTRAL] Looks like the claim was denied by their major medical from what we have.
[CUSTOMER][NEUTRAL] So you guys are a secondary?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Because it looks like Cigna.
[CUSTOMER][NEGATIVE] Denied this
[CUSTOMER][NEUTRAL] Let me double check.
[CUSTOMER][NEUTRAL] Just to make sure I have the right information.
[CUSTOMER][NEGATIVE] Yeah, it looks like Cigna denied this.
[CUSTOMER][NEGATIVE] It's not payable.
[AGENT][NEUTRAL] So yeah, that's the EOB that we're looking at as well. The signa EOB that was provided with this claim looks like they did deny it. And we only pick up when their major medical um applied benefits towards their deductible co-pay co-insurance.
[CUSTOMER][NEUTRAL] And then you guys.
[CUSTOMER][NEUTRAL] Oh so.
[CUSTOMER][NEUTRAL] So do you guys apply this to patient responsibility?
[AGENT][NEUTRAL] We don't have any determination in regards to that. That's up to your determination, but this coverage is secondary, so we only pick up towards their out of pocket for a co-pay, deductible co-insurance. Looks like they said that this was a non-covered from this Cigna EOB.
[AGENT][NEUTRAL] By their primary.
[CUSTOMER][NEUTRAL] So if this is not covered by the primary,
[CUSTOMER][NEUTRAL] I mean that's not our determination. That's up to the insurance.
[AGENT][NEUTRAL] Then we wouldn't cover it unless we only pick up as secondary when it's applied towards their deductible co-pay co-insurance. Now, if this claim is reprocessed by their major medical Cigna and then they apply, apply benefits towards their deductible co-pay co-insurance, then that's when we come in and pick up.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] So what if the primary doesn't pick up anything and they they deny that to the total charges the patient responsibility.
[AGENT][NEUTRAL] Then we don't pay anything. We only pay benefits if major medical provides benefits. If the claim is later paid by the major medical, then we would just need an updated EOB and we will consider benefits under the policy.
[CUSTOMER][NEUTRAL] So you guys only pay major medical.
[CUSTOMER][NEUTRAL] Is that correct?
[AGENT][NEUTRAL] We, we only pick up if their major medical has applied benefits towards their deductible, co-pay, co-insurance only.
[CUSTOMER][NEUTRAL] medical.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] Oh, OK.
[AGENT][NEGATIVE] So if they denied the claim altogether, then it wouldn't be covered under our coverage either.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Oh OK.
[CUSTOMER][NEUTRAL] OK, um, do you have an explanation of benefits that you guys could fax over to me because we don't have anything from you guys.
[AGENT][NEUTRAL] Yeah, it showed that it was mailed out. Looks like we mailed it to.
[CUSTOMER][NEUTRAL] Let me see.
[AGENT][NEUTRAL] See what address we mailed it to. It looks like it was the wrong file [PII].
[CUSTOMER][NEUTRAL] Oh wait let me see something.
[CUSTOMER][NEUTRAL] No way it benefits. OK, here it is.
[CUSTOMER][NEUTRAL] Yes, it's benefits are payable only if your major medical insurance provider provides benefits.
[CUSTOMER][POSITIVE] OK, yeah, it looks like we got that.
[CUSTOMER][NEUTRAL] I should have seen that before that before I called you.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Is there anything else I can assist you with today, [PII]?
[CUSTOMER][POSITIVE] No, that's all I appreciate your help.
[AGENT][POSITIVE] You're welcome thanks for calling APO you have a good day.
[CUSTOMER][NEUTRAL] You too bye.
[AGENT][POSITIVE] Thanks bye.