AccountId: 011433970860
ContactId: 99f9daf5-346c-44bc-a7fb-c75c550a092b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 438570 ms
Total Talk Time (AGENT): 235463 ms
Total Talk Time (CUSTOMER): 141546 ms
Interruptions: 1
Overall Sentiment: AGENT=0.4, CUSTOMER=1.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/07/99f9daf5-346c-44bc-a7fb-c75c550a092b_20250207T17:32_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII] over on the care team. How are you today?
[AGENT][POSITIVE] I'm doing well thanks [PII] how are you?
[CUSTOMER][NEUTRAL] Doing all right, thank you. I have a provider on the line uh calling regarding an HI claim um for one of the items it's stating that we needed the itemized bill from a physician if it was not the surgeon. Um, she said that she did send that information, so she wants to review what was submitted.
[AGENT][NEUTRAL] Certainly, um, do you have a policy number here?
[CUSTOMER][NEUTRAL] Yes, it is 02450890.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And it is for the claim uh ending in 367.
[AGENT][NEUTRAL] And do you um have the information of who I'm speaking to?
[CUSTOMER][NEUTRAL] Yes, her name is [PII].
[CUSTOMER][POSITIVE] And I've got that call back if you need that.
[AGENT][NEUTRAL] OK, go ahead when you're ready please.
[CUSTOMER][NEUTRAL] It is 209.
[CUSTOMER][NEUTRAL] 3952729
[CUSTOMER][NEUTRAL] And she's specifically asking about the procedure code 9984.
[AGENT][NEUTRAL] That
[AGENT][NEUTRAL] 99 OK 9284 OK and it's [PII], correct? Did I hear that right? OK, alright, you can transfer her and the patient has been verified, [PII].
[CUSTOMER][NEUTRAL] Right, yes.
[CUSTOMER][POSITIVE] All right, thanks [PII].
[CUSTOMER][NEUTRAL] Oh yes it's all been verified.
[AGENT][POSITIVE] OK thanks great, thank you so much, bye.
[CUSTOMER][POSITIVE] Thank you bye bye.
[AGENT][NEUTRAL] Hi, is this [PII]?
[CUSTOMER][NEUTRAL] Uh yes, it's [PII].
[AGENT][NEUTRAL] My apologies, [PII]. My name is [PII] and I'm in the claims department.
[CUSTOMER][NEUTRAL] That's OK.
[CUSTOMER][POSITIVE] OK, good morning, how are you?
[AGENT][POSITIVE] And I understand I'm doing well thank you how are you?
[CUSTOMER][POSITIVE] I'm good thank you.
[AGENT][NEUTRAL] OK, so, um, I understand you have some questions in regards to [PII]'s claim that claim number 3542367 for data service [PII].
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And um [PII] had mentioned that you had a question up most specifically about the um emergency room professional fee of 99284.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] OK, so let's start.
[AGENT][NEUTRAL] Just to let you know it's a verification of their coverage, not a guarantee of payment. I have to read that to you. So this policy is actually a limited medical hospital indemnity plan and it does have an outpatient sickness benefit rider, but it does not, um, it does not cover a diagnosis of uh injury or accident. So what happened with this claim is it looks like uh they had some sutures.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, under the claim and we paid that under their surgical benefits. However, the emergency or professional fee, um, is not covered due to the accidental diagnosis.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK and um so the remaining balance is that patient responsibility?
[AGENT][NEUTRAL] Yes, let me check some information also please here just one moment.
[CUSTOMER][POSITIVE] Mhm, yes, thank you.
[AGENT][NEUTRAL] OK, so because this is a limited hospital indemnity, um, we do not, um, we do not.
[AGENT][NEUTRAL] Uh,
[AGENT][NEUTRAL] We do not tell you what to bill to the patient and the reason being is there is no um there is no network and there is no contractual adjustment made. If there's a payable benefit, we'll pay that benefit, but we can't tell you what to charge the patient that would be between the provider and the patient as far as, um, yeah, that balance now um.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] He does have um one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Do you know if you're part uh you participate with multi plan?
[CUSTOMER][NEUTRAL] Um, let me check because I know for a period of time we did, but let me just double check one moment.
[CUSTOMER][NEUTRAL] Mm, no, because it looks well yes actually we do have um a multi plan network that was effective we've been in contract with since [PII], so if there's a if it can be reprocessed under that network.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Well, again, um, because it is, um, that limited medical benefit like I said, the claims go to IMA that's where they're in, uh, uh, and then they forward them to to us at APL to process any benefits that might be payable. However, they are encouraged that the um insurers are encouraged to use multi-plan providers in hopes that they may get a greater savings because this is not a major medical insurance it is limited hospital indemnity.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, well, the only thing I could, um, for me to process it under that multi plan or to apply that discount, I would need an EOB showing that it processed under that network.
[AGENT][NEUTRAL] Uh, OK.
[CUSTOMER][NEUTRAL] With those adjustments, otherwise if it if I don't have that if it if it processed out of network, then I have to process it as out of network and then the balance does come patient responsibility.
[AGENT][NEUTRAL] OK, um, yeah, and our, you know, our, our, our explanation of benefits are not specific as to what, um, you know, how they're processed they just processed in the system based on where what we received from IMA, um, but unfortunately, yes, it's not, um.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] So it's not and you can't get it to reprocess to reflect the network discount?
[AGENT][NEUTRAL] Um, are you able to hear me still? I'm sorry about that, [PII].
[CUSTOMER][NEUTRAL] Yeah, I think it did cut out though so.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Did you have any other questions?
[CUSTOMER][NEUTRAL] Um, well, I don't know, did if you did you hear my question about are you able to have it reprocessed under the network or no?
[AGENT][NEGATIVE] Unfortunately not like I said, our explanation of benefits are not going to um show that multipla discount uh being or under that multi plan network it's just gonna show under the same way as it was processed the first time unfortunately.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, no worries, um, is there a call reference number for today?
[AGENT][NEUTRAL] Certainly [PII], the call reference number used my name in today's date [PII].
[AGENT][NEUTRAL] Last initial [PII]
[CUSTOMER][POSITIVE] Great. Thank you very, oh sorry.
[AGENT][NEUTRAL] And I'm sorry, last initial, yeah, that's OK. Uh, last initial is [PII] and then today's date would be your call reference.
[CUSTOMER][NEUTRAL] Didn't mean to interrupt you. I do apologize.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] I appreciate it thank you so much for your help.
[AGENT][POSITIVE] You're welcome have a great day and a great weekend.
[CUSTOMER][POSITIVE] Thank you you too.
[AGENT][NEUTRAL] OK bye bye.
[CUSTOMER][NEUTRAL] Bye bye.