AccountId: 011433970860
ContactId: 4501e6da-e932-4c5b-82bd-e35227f29b54
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 733169 ms
Total Talk Time (AGENT): 223986 ms
Total Talk Time (CUSTOMER): 233127 ms
Interruptions: 0
Overall Sentiment: AGENT=0, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/07/4501e6da-e932-4c5b-82bd-e35227f29b54_20250407T15:40_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Oh you
[CUSTOMER][NEUTRAL] Hey, um, I got 150.
[CUSTOMER][NEUTRAL] Um, my name is [PII], and my husband's a patient. His name is [PII], and I just got an explanation of benefits from y'all, and y'all have this as an office visit, but this was a quest lab work.
[AGENT][NEUTRAL] OK. I'm happy to look at a claim. Do you have the claim number or your policy number?
[CUSTOMER][NEUTRAL] Um, let's see, claim number is 358-089-0.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me pull this up here. Give me just a moment.
[CUSTOMER][NEUTRAL] And then making
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] All right. And then on the policy, I will need to verify please, name and date of birth.
[CUSTOMER][NEUTRAL] Oh, his name is [PII] and the date of birth is [PII].
[AGENT][NEUTRAL] Thank you. And then I'll need to verify the physical address.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so the claim does show denied as office visits aren't covered based off of the procedure code and the way that they filed, it looks like the claim on this.
[CUSTOMER][NEUTRAL] Because I sent the paperwork in with Quest, you know, with Quest, and you get the paperwork showing lab work.
[AGENT][NEUTRAL] Let me pull up and see what was submitted on this one. Give me just a moment please.
[CUSTOMER][NEUTRAL] Because they told me it would be applied towards his, he's got a $100 deductible.
[AGENT][NEUTRAL] OK. Mhm.
[AGENT][NEUTRAL] Was this a claim that was submitted um that you did yourself?
[CUSTOMER][NEUTRAL] I paid the claim.
[CUSTOMER][NEUTRAL] Because it was, y'all tell me I had to pay it because there was a $100 deductible.
[CUSTOMER][NEUTRAL] It would be applied to a deductible.
[AGENT][NEUTRAL] OK, because, so the claim number that you gave me was not for Quest Diagnostics, that was a different provider.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The one ending in 0890.
[CUSTOMER][NEUTRAL] Well, did you show any for um
[CUSTOMER][NEUTRAL] For uh Quest Diagnostics.
[AGENT][NEUTRAL] So I do show one here and it looks like.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] But the bill amount was up.
[CUSTOMER][POSITIVE] I mean, maybe I'm getting it
[AGENT][NEUTRAL] Yeah, the billed amount was just applied towards the deductible of $100.
[AGENT][NEUTRAL] And the only other denial I see on there is just that benefits are.
[CUSTOMER][NEUTRAL] The
[CUSTOMER][NEUTRAL] Oh, I see, I see.
[CUSTOMER][NEUTRAL] For diagnostics I paid 1762 and 1154 and 581.
[CUSTOMER][NEUTRAL] I paid that on [PII].
[CUSTOMER][NEUTRAL] Yeah, and I said, I submitted it, uh, EOB from Quest.
[CUSTOMER][NEUTRAL] I still may have at home.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] You and that equals 3497.
[CUSTOMER][NEUTRAL] But that wasn't for the office visit.
[AGENT][NEUTRAL] Yeah, so one of them, it looks like the amount was applied towards the deductible.
[AGENT][NEUTRAL] And then one of them shows.
[CUSTOMER][NEUTRAL] Yeah, but you don't have that.
[CUSTOMER][NEGATIVE] It says not covered service, it says outpatient.
[CUSTOMER][NEUTRAL] Where it says calendar deductible met 3497 so it was applied to the deductible.
[AGENT][NEUTRAL] One of the quest, yeah, so one of the claims for Quest, the amount was applied towards the deductible.
[AGENT][NEUTRAL] And then there were some denials on here stating that there were only benefits payable if the major medical was paying, since this is the secondary.
[CUSTOMER][NEUTRAL] OK, wait a minute.
[CUSTOMER][NEUTRAL] Repeat.
[CUSTOMER][NEUTRAL] Repeat that again. I, I didn't hear you.
[AGENT][NEUTRAL] Benefits are only payable if major medical provides benefits.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] We're the secondary insurance, so this is only gonna pay if major medical.
[AGENT][NEUTRAL] Uh, been paid and if they did, then you could send the explanation of benefits.
[CUSTOMER][NEUTRAL] Mhm. So what does that mean? Any lab work that he has done, it's not covered?
[AGENT][NEUTRAL] Only if the major medical is paying on it.
[AGENT][NEUTRAL] If the major medical does not cover.
[AGENT][NEUTRAL] The incurred charge.
[CUSTOMER][NEUTRAL] Well they have a contracted rate, so they must be doing something.
[AGENT][NEUTRAL] If the major medical is paying something, then we need the explanation of benefits showing what they paid towards the date of service.
[CUSTOMER][NEUTRAL] OK, so I'm trying to understand this if he gets more lab work and say it's $200 and so we since we miss the 3497, then we would be responsible for the amount up to $100.
[AGENT][NEUTRAL] Well, the deductible has already been met, I believe, on this. Let me see.
[CUSTOMER][NEUTRAL] I don't know if it's been met or not because this is the statement I got and it says um calendar calendar year deductible met and it's not outpatient 3497.
[AGENT][NEUTRAL] Let me see what's been met for the year.
[CUSTOMER][NEUTRAL] Oh yeah, it has been met. I'm sorry. I'm getting confused.
[CUSTOMER][NEUTRAL] Because I just, I just looked up his account the other night and his deductible has been there.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I don't know about the deductible with y'all.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I don't know about y'all's $100 deductible, but on his medical, he has met his deductible.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So, on the secondary policy, deductible taken is 3497 out of $100. So there is a remaining, yes, amount, it looks like uh
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] $65.03.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So,
[CUSTOMER][NEUTRAL] So then once he meets that, then his, then it'll be covered.
[AGENT][NEUTRAL] [PII]t, it wouldn't go towards then the deductible, then the plan would just be paying out on the outpatient benefit, which is a total of $6000 for the calendar year, uh, once the $100 deductible has been met.
[CUSTOMER][NEUTRAL] OK, um, let me understand something else. OK, it's 6000 outpatients, and then what if he's admitted into the hospital?
[AGENT][NEUTRAL] The inpatient amounts.
[CUSTOMER][NEUTRAL] And it transfers to the
[AGENT][NEUTRAL] Yeah, the impatient amount for the calendar year is 6000 also.
[CUSTOMER][NEUTRAL] Oh, OK. I didn't, that's where I was getting confused at too, you know, you almost need an attorney to figure these things out. So it's $6000 outpatient and $6000 if he's admitted into the hospital.
[AGENT][NEUTRAL] Correct. And the inpatient, yeah, and the inpatient has no deductible.
[CUSTOMER][NEUTRAL] That's what you're telling me.
[CUSTOMER][NEUTRAL] Yeah, no, I'm looking at this thing and it says total bill charge is $1,066. I'm thinking that's.
[CUSTOMER][NEUTRAL] I'm thinking that came from Dr. [PII], if I'm not mistaken. Am I right?
[AGENT][NEUTRAL] Uh, let's see.
[CUSTOMER][NEUTRAL] No, not [PII], Doctor [PII].
[CUSTOMER][NEUTRAL] But, but they probably just build it on [PII], but I'm, I'm, I'm assuming that's what it is.
[AGENT][NEUTRAL] Yeah, it just comes over as [PII].
[CUSTOMER][NEUTRAL] Yeah, and then what he did, he sent him to do lab work. That's where that 3497 is.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEUTRAL] All right, um.
[CUSTOMER][NEUTRAL] So, so when he sent him some lab work again, if it's more than 6503, then y'all cover the rest.
[AGENT][NEUTRAL] Mhm, yeah, and it looks like they're
[CUSTOMER][NEUTRAL] Because they, because they're supposed to send it over to y'all, right?
[AGENT][NEUTRAL] Yeah, so that's what I was gonna say the easiest way is if they'll go ahead and submit as a secondary to us and then yeah, just let them know that we're the secondary.
[CUSTOMER][NEUTRAL] OK, to where [PII], the one that sends out the bill?
[AGENT][NEUTRAL] Right, they submitted the claim to us as the secondary.
[CUSTOMER][POSITIVE] Yeah, I think they have all that information on file, but I'm gonna have to, I'm gonna have to check with them and make sure. OK, all right then and thank you for your help, ma'am and you have a blessed day, OK?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] You too. Bye bye.