AccountId: 011433970860
ContactId: 84187318-19cf-4251-91e7-b3a6dee20c71
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 565609 ms
Total Talk Time (AGENT): 219716 ms
Total Talk Time (CUSTOMER): 327410 ms
Interruptions: 0
Overall Sentiment: AGENT=0.4, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/09/84187318-19cf-4251-91e7-b3a6dee20c71_20250509T15:52_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII]. I am calling you from Northside Hospital, and I have one of your members here that just had a baby, and I'm trying to get medical benefits in regards to like deductible out of pocket coinsurance and co-pay if there's any.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Is it [PII] or [PII]? How do you spell your name?
[AGENT][NEUTRAL] My name is [PII] initial [PII] my last name is [PII].
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, perfect.
[AGENT][NEUTRAL] And [PII], may I have it?
[CUSTOMER][NEUTRAL] OK, Ms. [PII].
[AGENT][POSITIVE] May I have a good
[CUSTOMER][NEUTRAL] Go ahead, I'm sorry.
[AGENT][NEUTRAL] May I have a good contact number in case we're disconnected and the member's policy number?
[CUSTOMER][NEUTRAL] Oh sure. Oh, you know, I just gave somebody, I think they did I give them the wrong number? So let me see. I just, I think I gave them 770. Let me verify my number. Sometimes the brain doesn't work.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And it's Friday.
[CUSTOMER][NEUTRAL] I'm like wait
[CUSTOMER][NEUTRAL] I know I'm like, [PII], [PII], [PII], help me. Did I give them the wrong number? I, jeez, what's what's what's up with me today? OK, so it is, let's see my numbersella, what's your number?
[CUSTOMER][NEUTRAL] I'm looking at something that I sent to see my info. OK, so it is I gave the right number, so it's 770.
[CUSTOMER][NEUTRAL] 844
[CUSTOMER][NEUTRAL] 3311.
[CUSTOMER][NEUTRAL] And that's a direct line.
[AGENT][NEUTRAL] Thank you. And then may I have the member's policy number?
[CUSTOMER][NEUTRAL] Sure, their policy number is, let's see which where is it on here? I have it's uh APL insurance the same one, right? I have a group number. I don't see a policy number.
[AGENT][NEUTRAL] Uh, do you have the card there?
[CUSTOMER][NEUTRAL] Um, where would I find? I have, I'm looking at a copy of it. He sent it to me through the um email.
[AGENT][NEUTRAL] OK, you're looking for the in-hospital or outpatient policy?
[CUSTOMER][NEUTRAL] So I have a group.
[CUSTOMER][NEUTRAL] Oh, in hospital. OK, perfect. In hospital, so it's 0257.
[CUSTOMER][NEUTRAL] 254 3.
[CUSTOMER][NEUTRAL] ML 7.
[CUSTOMER][NEUTRAL] And it's for maternity inpatient benefits.
[AGENT][NEUTRAL] Can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Her name is [PII].
[CUSTOMER][NEUTRAL] Um, [PII] and it's [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And for inpatient, the member has up to $3000 per calendar year to use for inpatient expenses.
[CUSTOMER][NEUTRAL] Uh, [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So what is that deductible out of pocket or what?
[AGENT][NEUTRAL] We pay, this is her secondary insurance. We pay towards the copay, deductible and co-insurance of coverage charges after her primary up to the $3000 a year.
[CUSTOMER][NEUTRAL] So the 3000 would be her deductible.
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Because uh what, what would it because we have deductible out of pocket co-insurance and co-pay, so what is yours considered?
[AGENT][NEUTRAL] No, so.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] OK, if you allow me to explain it to you. So, UnitedHealthcare is the major insurance. They apply, they charge the co-pay or the deductible, we help pay it. So whatever they charge, once their bills, if the patient needs to pay upfront for that to have her services, then when we receive the claim as second on the back end,
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The insurer can be reimbursed or if something still owed to you all, we can pay you all, but it's up to the $3000 so we're not charging it, we help pay it.
[AGENT][NEUTRAL] It's charged from primary.
[CUSTOMER][NEUTRAL] OK, so, so you said they have United Healthcare as their primary?
[AGENT][NEUTRAL] Let me double check because sometimes it doesn't cross over, so hold on one second.
[CUSTOMER][NEUTRAL] Is that what you're saying?
[CUSTOMER][NEUTRAL] Yeah, let me just look and see.
[CUSTOMER][NEUTRAL] 2504403716.
[CUSTOMER][NEUTRAL] Yeah, they do have United Healthcare.
[AGENT][NEUTRAL] Yes, it's United Healthcare.
[CUSTOMER][NEUTRAL] But, but it is, it's more than that, it's not 3000.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Uh, 250440-3716. I'm just looking at United Healthcare. They're, um, let me just double check here.
[CUSTOMER][NEUTRAL] So for the individual, their individual deductible is $6350.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And the out of pocket is $6970 remaining and then they have a co-insurance of 20%.
[CUSTOMER][NEUTRAL] So I'm just trying to understand how to calculate that.
[AGENT][NEUTRAL] So primary has its own its own benefits and secondary has its own benefits. So whether they charge a million, hold on.
[CUSTOMER][NEUTRAL] Right, so you
[AGENT][NEUTRAL] Whether they charge a million dollars or $1 the max on their secondary policy is $3000 so that's all we can pay towards any claims that come in.
[CUSTOMER][NEUTRAL] So my question is, should, should they put it on on the system as a secondary insurance or they should just use United Healthcare and then have you reimburse them?
[AGENT][NEUTRAL] So if
[AGENT][NEUTRAL] No, we need to be billed as secondary. So you're to bill United Healthcare and let them apply, and then with the explanation of benefits and the itemized bill from you all, you'll send it to us for us to apply a second.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So on my calculator, where do I put the $3000?
[AGENT][NEUTRAL] You don't, that's just the max that they have to use towards inpatient expenses. So we don't know if that whole $3000 will be applied, we have to process the claim, but that's what they have to use.
[CUSTOMER][NEUTRAL] In what category?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So we don't we just don't charge them anything at all until the hospital bill them, is that what you're saying?
[CUSTOMER][NEUTRAL] Because I don't understand, so I'm trying to figure it out.
[AGENT][NEUTRAL] Are you, aren't you Northside?
[AGENT][NEUTRAL] OK, so,
[CUSTOMER][NEUTRAL] Yes I am.
[AGENT][NEUTRAL] So Northside, so you all are the
[AGENT][NEGATIVE] I don't understand. So primary, they're gonna, she's gonna have the baby, you're going to bill UnitedHealthcare.
[AGENT][NEUTRAL] UnitedHealthcare is going to
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Whatever their benefits are, and they're going to provide you with an explanation of benefits. You're then going to take the explanation of benefits and your universal bill from Northside billing and send it to us a second.
[CUSTOMER][NEUTRAL] Hm
[AGENT][NEUTRAL] For us to process the remaining balance and if she's owed anything, we'll pay her. If you all are owed anything, we'll pay you. If there's something left over, we don't determine patient responsibility, so you all can bill or write off, but it's primary and second.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I'm gonna leave that to the billing department then I'm not gonna do any calculation because I'm a little confused as to I mean it's on there as a second so my thing is they should not put a second insurance on there they should wait until.
[CUSTOMER][NEGATIVE] United Healthcare's bill and then go to the second insurance but it shouldn't be on there as dual insurance for the patient.
[CUSTOMER][NEUTRAL] In order for me to do a calculation, I won't be able to do a calculation unless I have numbers to put in there, but there's no category for me to put the 3000, so I'll just let the billing office deal with that.
[CUSTOMER][NEUTRAL] Do you understand what I'm saying?
[AGENT][NEUTRAL] Um, a little bit. I don't know where the, there's no calculations yet until the bills come out. You're just getting all the information with the coverage.
[CUSTOMER][NEUTRAL] Right, but
[CUSTOMER][NEUTRAL] Right, but what we normally do is, for example, when they, when we have insurance, they should, they only have United Healthcare, they have a deductible out of pocket and co-insurance to meet before the insurance pays their portion. So we normally do a calculation and we request a portion of that, um, from the patient until they get their total bill.
[AGENT][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] So we get like 13 portion of that, but I won't be able to do that now because it has dual insurance and they're looking for information for the second insurance and we don't have a category to put that $3000 in.
[AGENT][NEUTRAL] Right, because the 30.
[CUSTOMER][NEUTRAL] That's on the back end but that's.
[AGENT][NEUTRAL] Right, so the only thing that you would be taking would be whatever their primary charging them as a deductible, that's what you're collecting.
[CUSTOMER][NEUTRAL] Go ahead.
[CUSTOMER][NEGATIVE] Right, but the problem is they put them in as dual insurance and it's asking for the second insurance information, so that has to be deleted from there in order for this to be processed.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right, OK.
[CUSTOMER][NEUTRAL] So yeah, do, do, so that's they just messed it up that way but I'm just going to leave it as is and then let them worry about that later in the business office because it's not allowing me to do the calculation because they have the patient as to insurance and they're not to commercial insurance. This is a separate insurance, the APL.
[AGENT][NEUTRAL] Right. Mhm.
[CUSTOMER][MIXED] Yeah, so they just messed up, messed it up, but it's OK.
[CUSTOMER][NEUTRAL] We'll just I'll call the business office and I'll find out what what to do with this information. So Miss [PII], will you please give me a reference number?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So there's no call reference number, but you can use my name and today's date. No, we don't give call reference numbers.
[CUSTOMER][NEUTRAL] There's none.
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] OK, 9 2025.
[CUSTOMER][POSITIVE] Thank you so much. I'm gonna try to still understand this.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] You're very welcome, Ms. [PII]. Was there anything else I can assist you with today?
[CUSTOMER][POSITIVE] Alright thanks.
[CUSTOMER][POSITIVE] No, you have a good day. Thank you.
[AGENT][POSITIVE] You also. Thanks for calling APL. Bye-bye.
[CUSTOMER][NEUTRAL] OK bye.
[CUSTOMER][POSITIVE] OK thanks bye.