AccountId: 011433970860
ContactId: 4f3849cb-a0a8-4d86-9d47-4d614409a5d7
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 734460 ms
Total Talk Time (AGENT): 402554 ms
Total Talk Time (CUSTOMER): 296042 ms
Interruptions: 0
Overall Sentiment: AGENT=0.5, CUSTOMER=1.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/05/4f3849cb-a0a8-4d86-9d47-4d614409a5d7_20250205T14:29_UTC.wav
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[AGENT][NEUTRAL] For contacting ATL, my name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. My name is [PII]. I'm calling from Fortune Insurance. How are you?
[AGENT][NEUTRAL] I'm fine, how are you?
[CUSTOMER][POSITIVE] I'm doing pretty good. um, I'm calling from a broker's office in reference to um an employee of one of our groups that's having issues um with the uh uh uh understanding how much she owes, and she asked me if I could please um get everything clarified for her because she has.
[CUSTOMER][NEGATIVE] Her medical and then she's got APLs, the secondary, and the facility that's telling her that the APL was applied where it doesn't make sense with the amount that she owed so I feel like something she's being misinformed and I was hoping you could help me um get this straightened out as far as who APL has paid towards her maternity ser services.
[AGENT][NEUTRAL] Yes, we can certainly look at her, um, at her claims and then we can, um, we can look at that. We can see what was paid. We can go back to the uh the so what is her, um, policy number?
[CUSTOMER][POSITIVE] OK, awesome
[CUSTOMER][NEUTRAL] Um, 00, hold on, let me look it up right now. I'm gonna log into the.
[CUSTOMER][NEUTRAL] Because I know that I can see I could submit claims, but I don't, but I don't think I can see claims on the portals, but let let I definitely.
[AGENT][NEUTRAL] Sure. What is your
[AGENT][NEUTRAL] What's your group number?
[CUSTOMER][NEUTRAL] The group number is 21471.
[CUSTOMER][NEUTRAL] And I'm looking up her, her policy number now.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] It's she's under Centurion Restaurant Group. Her name is [PII].
[CUSTOMER][NEUTRAL] Bruno and I'm sorry, it's hourglassing, um.
[CUSTOMER][NEUTRAL] And here we go. I found her Briseno, her policy number was APL.
[CUSTOMER][POSITIVE] That's how I was laughing again.
[AGENT][NEUTRAL] And how do you spell her last name, please?
[CUSTOMER][NEUTRAL] Um she spells it [PII]
[CUSTOMER][NEUTRAL] And her policy number is 2273057.
[AGENT][POSITIVE] Great, thank you. So we'll just look that up and and is there a callback number I can have in the event that we're disconnected?
[CUSTOMER][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Yes, of course. My direct line is [PII].
[AGENT][POSITIVE] Great. Thank you so much. Let's look at her claims.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] The date of service is [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] So we have 2 inpatient uh claims, um.
[AGENT][NEUTRAL] There's also the, the hospital one, so let's uh
[AGENT][NEUTRAL] Let's look at those, um.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So the very first one, maybe that we should look at would be the hospital one. Is that, is there any particular claim that she's looking at that she has a question about or is it?
[CUSTOMER][NEUTRAL] Yeah, so yeah, there's 2, yeah, there's 2 that she's getting charged for and I believe um.
[CUSTOMER][NEUTRAL] I, I, I don't know, I, I'm trying, I already know from the, from the Humana how much she owes for each provider. So the hospital claim came in for like $37,000 and her co-insurance, the deductible was applied to the mostly to the physician. So the hospital's telling her she owes a coin for the coinsurance of 10%, $1,983.
[AGENT][NEUTRAL] Yeah, that's, that's how much she is. So let's look at that. Um, that claim.
[CUSTOMER][NEUTRAL] So did APL pay that?
[AGENT][NEUTRAL] Yes, ma'am, we did. Um, so the claim number on this is 35.
[AGENT][NEUTRAL] 46513. Now, we received that particular claim. Now, the only claims that I, I will tell you, it looks like we have anesthesia bills. We have the hospital bill and that's it. I don't have the physician's ones, uh, yet, so, but let's look at the one that we do have that was just uh processed on [PII]. Now, this is the uh South Miami Hospital for um [PII].
[AGENT][NEUTRAL] And what has happened with her explanation of benefits is that um
[CUSTOMER][NEUTRAL] So she, so this was the first admission she had an admission in in [PII].
[AGENT][NEUTRAL] Her uh
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] No, uh, I'm sorry. No, this, no, I'm sorry. I, I'm sorry. My, my phone is cutting in and out, um, and so that's probably, let me, let me, uh, restate this. So I have a bill, a hospital bill from [PII].
[CUSTOMER][NEUTRAL] Inpatient? Oh.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] To [PII].
[AGENT][NEUTRAL] Um, I'm, we're not talking about [PII] at all. We're talking about [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, perfect.
[AGENT][NEUTRAL] And, and her um her uh responsibility on this was this $1,983 which we sent out on the, uh, it would have gone out on the [PII] of
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] Uh, [PII].
[AGENT][NEUTRAL] So we, we did receive that, uh, that, that is what was, what was, um, I'm just checking, I'm looking at the check now to see whether they, you know, where it went, and, but yes, that, that was definitely paid. And let me give you, um.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Awesome.
[AGENT][NEUTRAL] And it looks like it's been cashed as of the of the [PII]. So if she's still getting bills for this, that might be a problem with the hospital. So let's look at the uh check that she received that we that we sent out, um, I will give you.
[CUSTOMER][NEUTRAL] Well, the one, the, the hospital, from what I'm seeing is the hospital, um, emailed her that she owed $2,285.
[AGENT][NEUTRAL] Uh.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right.
[CUSTOMER][NEGATIVE] That's not making sense.
[AGENT][NEUTRAL] 2000
[AGENT][NEUTRAL] 2200.
[AGENT][NEUTRAL] And $83 did you say?
[CUSTOMER][NEUTRAL] Well, they said that APL applied $4000 so they're trying, they were trying to collect for 2,285, and I just wanna know if that's accurate or not because based off the EOB that the that Humana sent.
[CUSTOMER][NEUTRAL] They, her patient responsibility was.
[CUSTOMER][NEUTRAL] So she may have to take this up at the hospital. Her responsibility was 9, 1,983. So if APL pay that full amount, then she shouldn't owe them not even a penny.
[AGENT][NEUTRAL] Which is what we paid.
[AGENT][NEUTRAL] Yeah, I'm wondering, um, now there is, uh, I'm looking at the Humana bill. Now there was, um, uh, we paid the $1,983 which is a co-insurance, which is what we paid, um.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] It looks like uh.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] There was a denied charge of $30,000 30,223 dollars. The only thing that I can that I can imagine is that uh the additional amount that they're asking is, is the difference between what Humana is, is, uh, considering, um.
[AGENT][NEUTRAL] Their agreed amount for this, uh, and we get this every now and again, uh, their agreed amount for this, uh, uh, procedure and what, and what is actually owed by the patient. But looking at the explanation of benefits from Humana.
[AGENT][NEUTRAL] Um, the co-insurance on this particular EOB that we receive and this and and as far as we know, Humana hasn't re educated.
[AGENT][NEUTRAL] Yeah, this this uh claim, so the EOB that we have was $1,983.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Which we paid and which was in that check was cashed on the [PII]. So they've gotten this money, it has been received.
[CUSTOMER][NEUTRAL] OK. So, so.
[CUSTOMER][NEUTRAL] Yeah, OK, so let's let's look at another claim because this is the one that they're, they're trying to collect more money from her, which is her physician that provided the uh services for the delivery at the hospital. Um, it is for doctor.
[AGENT][NEUTRAL] OK.
[AGENT][NEGATIVE] I I don't have his charge. Yeah, I don't have his charge. Now, let me tell you what I do have, um, and then, uh, like I said, there, we've only received a couple of things for this, um, and it's, uh, the anesthesia is what we've received. So I haven't received anything for a physician's, uh, for a, a physician's bill for this delivery.
[CUSTOMER][NEUTRAL] Oh, you don't have
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. Did you, did APL pay the anesthesiologist?
[AGENT][NEUTRAL] Yes, we did. Uh, we did receive um two separate, you know, how they, how they do the uh the anesthesia and two. So, uh yeah, this is for uh a doctor uh the [PII] and the last name is [PII] Now we received that um that claim, the explanation of benefits showed a deductible amount of 3.
[CUSTOMER][NEUTRAL] Yeah, yeah.
[AGENT][NEUTRAL] Uh, of, um,
[AGENT][NEUTRAL] $355.46. Uh, that was paid out. Uh, that was for that doctor. There was another um amount that was paid out uh for the, for the second part of the anesthesia and uh that was um uh $43.20. But the thing is that
[CUSTOMER][NEUTRAL] 43 I'm sorry, $43.20 you said?
[AGENT][NEUTRAL] Yes, yeah, there's, there's two different, two separate things on the anesthesia. The first anesthesia bill that we received, uh, the EOB had a uh co-insurance of $355.45 46 cents. The second one had $43.20.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] But I have received no physician's bills for this period of time. So if we, if she's receiving bills for that. Now, one of the things that she could do if, if she would like to, if she wanted to send in uh the bills herself so that we could then um uh
[CUSTOMER][POSITIVE] OK, perfect.
[AGENT][NEUTRAL] Uh, we could then go ahead and pay the, the benefit to her, um.
[AGENT][NEUTRAL] We could, she could do that. So what she may want to do is send in the existing bill that she's getting, and she can do that on our portal, and that's probably the fastest way and then just let us know that this is for the birth of her son.
[CUSTOMER][POSITIVE] Yeah, no, I'm I'm familiar with that because I help.
[CUSTOMER][NEUTRAL] I help these um the employees out with the claims all the time. So if so it looks like she's got an APL inpatient benefit left over of $1,618. Am I right in that?
[AGENT][POSITIVE] Oh, that's wonderful. Yeah.
[AGENT][NEUTRAL] Uh, yeah, let me just check here, um.
[AGENT][NEUTRAL] So for her uh balance for her um
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] 2024.
[AGENT][NEUTRAL] Uh, she's only used, um.
[AGENT][NEUTRAL] $2,381.66 of her benefits. So, uh.
[CUSTOMER][NEUTRAL] Yep, that's what I thought. OK.
[CUSTOMER][NEUTRAL] So she's got a remaining $1,618.34 left.
[AGENT][NEUTRAL] Uh, yeah, it looks like that. I believe so.
[CUSTOMER][POSITIVE] OK. All right, perfect.
[AGENT][POSITIVE] Uh, yeah, that's exactly what she's got.
[CUSTOMER][POSITIVE] OK. Awesome. Well, thank you so much. That's exactly what I needed to understand. I feel confident that I uh have a uh a good grip on what's happening here. So I will, uh, circle back around with her. I'll let her know what's going on so that we could try to get that doctor, uh, [PII], at least a portion of it paid for through her gap insurance.
[AGENT][NEUTRAL] Yes, yeah, and if she has any questions or if you have any questions, please just let us know. Now is there anything else, is this the only thing that we're that we're looking at any other bills that that she's having, uh, getting, uh, and that, that we should be taking care of ourselves?
[CUSTOMER][POSITIVE] No, no, no, we're, we're solid. Thank you so much. I really appreciate you. I hope you have a great rest of your day.
[AGENT][POSITIVE] OK, thanks for contacting APL you have a very good day.