AccountId: 011433970860
ContactId: 7b37826e-6103-47b4-a39f-cc2b0d750ad6
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 733140 ms
Total Talk Time (AGENT): 524797 ms
Total Talk Time (CUSTOMER): 192617 ms
Interruptions: 1
Overall Sentiment: AGENT=0.8, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/17/7b37826e-6103-47b4-a39f-cc2b0d750ad6_20250417T17:40_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How may I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] over in customer care. How are you doing today?
[AGENT][NEUTRAL] Doing well, [PII] how are you?
[CUSTOMER][NEUTRAL] I'm doing all right. um I have a broker on the line he's the contact for
[CUSTOMER][NEUTRAL] A group anyway he's checking on an insured's claim that was denied and I was reading the denial to him and.
[CUSTOMER][NEUTRAL] I was wondering if maybe you could look at it with me or help him because it was denied saying primary provided full benefits and I see that on what was submitted but they also submitted patient responsibility so I don't I'm confused I guess.
[AGENT][NEUTRAL] Sure, what's the policy number sir?
[CUSTOMER][NEUTRAL] Uh, policy number is 015.
[CUSTOMER][NEUTRAL] 24159.
[CUSTOMER][NEUTRAL] And it's for uh [PII].
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] OK, and it's Medlink. OK. And is it that last claim process the ending in 772?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh yes, ma'am. Uh-huh, yup.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And so I did see like on the EOBs that they submitted it looks like it was, you know, highlighted the deductible copays amount are 0 and I did explain that I'm like, well, the deductible and copay shows 0, and he's like, well, but it shows patient responsibility, so why wouldn't it have paid that.
[AGENT][NEUTRAL] I'm pulling it up now.
[CUSTOMER][POSITIVE] No, no worries.
[CUSTOMER][NEUTRAL] I'm new to all this still, so trying to figure it out, yeah.
[AGENT][POSITIVE] Yeah, understood, understood, right. Well, um, let me just take a look at it and I mean I'll be happy to take the call but let me just take a look and see if I can help you.
[CUSTOMER][POSITIVE] No, no, I appreciate you.
[AGENT][NEUTRAL] At least you know what you're looking at, sure. OK, so when we look at that EOB it shows um co-pay and deductible amounts are 0 on that 10:15 it looks like emergency room, so.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let me look at the other.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK, these meddling policies are very specific as to um what's covered #1 and #2, it's strictly copay and deductible. So while it's saying there's a patient responsibility, it has to show a co-insurance and or deductible amount for the policy to cover that particular claim. So, um, and let's see, usually they give us a reason as to why on the EOB.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] And it's saying reason code is 46, you know, and it shows the emergency room, the service code, um, it really doesn't tell us why that patient amount is due, um, so when they're processing and there's no coinsurance or deductible amount, they deny it as paid in full by the primary basically because there's no um coinsurance and or deductible that's due for the EOBs now um.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Gotcha.
[AGENT][NEUTRAL] So that's kind of like I said, that's strictly on these meddling claims that's um because the policy does state that that's what it will cover. It will cover the co-insurance and or deductible amounts up to their maximum benefit allowed whether you'll be in the service inpatient outpatient. So, um, that's what it's looking like to me now why it shows the patient balance, I don't know. Anyway, go ahead.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right, right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Is there a question?
[CUSTOMER][NEUTRAL] No, I, but no, no, no, no, that makes perfect sense. Like I, that's how it was playing out in my brain, but sometimes because I just don't have enough experience, it's like I I don't feel like I explain it well to them because I was like, well, you know, there's no deductible copay or coinsurance on here, so there was nothing to pay but I didn't know about, I didn't know I was like, well why isn't there a coinsurance showing, you know, I, I didn't get that so.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] Uh.
[AGENT][NEUTRAL] Yeah, and these obese doesn't really explain to why it shows patient responsibility. Sometimes they get a little bit more detail, but these don't have any kind of detail. Now it does give us a message here. Let's see if this helps us.
[CUSTOMER][NEUTRAL] Right. OK.
[AGENT][NEUTRAL] Because sometimes there's an explanation.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And I just saw it on one of these.
[AGENT][NEUTRAL] So it's saying that the provider may bill you after your health plan benefits are paid because it doesn't really show typically a plan participant may billed by the provider of service because they have a deductible or co-insurance or the service is not covered by the health plan.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] So usually that's why because that percentage for some reason they show it is not covered by the plan, but it could be the patient responsibility however it's not applied against any coinsurance or deductible so therefore their medin plan doesn't pay that service.
[AGENT][NEUTRAL] Those that aren't covered or um you know like sometimes I'll charge like out of network this appears to be in network but for some reason like I said it does give us that blurb on the EOB telling us that it could be or it could or could not be that's just depending on the provider.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So they may or may not charge them that and that's why it's important to have the EOBs because again, these policies are specific to covering co-insurance and or deductible. So do you want me to speak to the broker?
[CUSTOMER][NEUTRAL] OK. All right.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Yeah, if you'll tell his name is [PII] if you'll tell him that I would greatly appreciate it and I just so appreciate you taking time to explain that to me. Thank you.
[AGENT][NEUTRAL] Certainly [PII]. Now, um, everything's been verified for the patient.
[CUSTOMER][POSITIVE] Yes ma'am, I did verify him again. I got him from Broker Resources bless his heart.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Got you.
[AGENT][NEUTRAL] OK, OK, so I won't try to make him do that again, but I'll do my best to explain to him what exactly is going on so you can transfer him when you're ready.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][POSITIVE] Thank you, 1 2nd.
[AGENT][POSITIVE] You're welcome sir have a good day if I don't speak with you again.
[CUSTOMER][NEUTRAL] Hello.
[AGENT][NEUTRAL] Hello, [PII].
[CUSTOMER][NEUTRAL] Yep.
[AGENT][NEUTRAL] Hi, my name's [PII]. I'm on the claim support team and [PII] transferred you over to me so I could further explain what's going on with the claims for Miss uh [PII], I think it is [PII]? OK, alright, so it looks like what happened for these services that were rendered, um, for 10-15-2024, it looks like it was an emergency room visit now um.
[CUSTOMER][NEUTRAL] Or
[CUSTOMER][NEUTRAL] Mhm. Sure. Mhm.
[AGENT][NEUTRAL] It appears that um the claims were denied um due to the um the primary insurance pays in full.
[AGENT][NEUTRAL] So what I did was I went ahead and pulled up the information that's on the explanation of benefits from the primary insurance. Now it's a little bit confusing, but hopefully I can help you understand. So what goes on with these Medlink plans they do um they are very specific to services that are covered under the plan.
[AGENT][NEUTRAL] So what happens is we'll work hand in hand with that major medical and it'll cover co-insurance and or deductible amounts for services uh that are covered under the plan up to their maximum benefit. Now in this situation, it appears that um the primary insurance didn't apply any co-pay or deductible amount. They show it as patient responsibility now um they're not that detailed um as far as um.
[AGENT][NEUTRAL] What happens with that um patient responsibility however they do say on the explanation of benefits from um from I believe it's Aetna, right? Yes, Allied I'm, I'm sorry.
[CUSTOMER][NEUTRAL] No, it's signal.
[AGENT][NEUTRAL] Yeah, Allied signal, OK.
[CUSTOMER][NEUTRAL] Yeah, yeah, that, yeah, allied to Allied yeah mhm it's not sing that, yeah, sing allied yeah.
[AGENT][NEUTRAL] OK, so I'm at.
[AGENT][NEUTRAL] Right, so on that page where they break down, you know, the total amount billed, the amount paid by the plan, and then your financial responsibility, they say this is the amount the provider of service may bill you after your health plan benefits are paid.
[AGENT][NEUTRAL] So that tells us that it's not necessarily patient responsibility it's up to that provider whether they apply that to the patient responsibility and then it says typically a plan participant may be billed by the provider of service because they have a deductible or co-pay or co-insurance or the service is not covered under the health plan.
[AGENT][NEUTRAL] Amounts shown here do not reflect any payments made at the point of service and that means that they don't show if the customer paid anything up front or anything like that that's what that means. And then it says a breakdown of your total financial responsibility is shown in the claim details. So when we pull up those the claim details, nothing was applied to deductible and co-insurance, and it says patient responsibility is 3578, and that's what I'm looking on the one line uh for the charges.
[AGENT][NEUTRAL] So, um, what that means is like I said that could or could not be applied to against the patient, um, but I do see that the services were processed in network so she should not receive a bill I wouldn't think. However, because it's not applied to coinsurance and or deductible, we don't cover the service under the Medlink policy.
[AGENT][NEUTRAL] Because it is specific to co-insurance and or deductible amounts um that are applied and then when we see that on the explanation of benefits that's how we would process it if there was a co-insurance or deductible due we would pay that amount.
[CUSTOMER][NEUTRAL] Mhm mhm.
[CUSTOMER][NEUTRAL] OK, OK.
[AGENT][NEUTRAL] So, um, does that, I mean, does that kind of help that explanation? uh like I said, other than, um, it looks like, like I said, it's paid at 80% everything it says it's, it's paid, um.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] It's been discounted by the PPO EPO network, so I'm not really sure um and then it also says there's a um the PPO information says there's a signal local plus discount patient not liable so I'm not sure if she's receiving a bill um from this particular provider.
[AGENT][NEUTRAL] But if she is, she, it would probably be best if she contacted them and asked them why because they didn't apply it to any coinsurance or deductible so that her basically this gap plan is not covering it because it's strictly for coinsurance and deductible.
[CUSTOMER][NEUTRAL] OK, alright, yeah I got it a little bit more, OK.
[CUSTOMER][NEUTRAL] All right.
[AGENT][NEUTRAL] Did you have any other questions I could try to answer [PII]? I know it's sometimes it can be a little bit confusing like I said, and like I said, she just can direct them to the portion on the on the EOB where it states that they may be billed, um, and one of them is 3578 and then the other one, let me see what that one says.
[CUSTOMER][POSITIVE] All right cool I appreciate it.
[CUSTOMER][NEUTRAL] No, that should be it for right now.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So if I have questions, I gotta upload a few for this group. If I have questions, can I, after I do it, can I call you or no I just call it?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, you can
[CUSTOMER][MIXED] There's a few claims out there and they're a good group and I don't think that they're, I think they're pretty profitable for you guys and um yeah, but.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] I mean, I would be happy to, to, you know, um, answer any questions you have. You can ask for me um if you have to call in again and again, I'm on the claim support, my name is [PII]
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Sure, what was your name again?
[CUSTOMER][NEUTRAL] [PII], OK, that's easy.
[CUSTOMER][POSITIVE] OK. All right, [PII], I appreciate it.
[AGENT][POSITIVE] You're welcome, [PII]. Thank you so much for calling APL. I hope you have a great rest of your day.
[CUSTOMER][NEUTRAL] All right.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][NEUTRAL] Bye.