AccountId: 011433970860
ContactId: c0c827a5-7320-46a1-ad97-21178a607ed6
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 576020 ms
Total Talk Time (AGENT): 189230 ms
Total Talk Time (CUSTOMER): 350232 ms
Interruptions: 3
Overall Sentiment: AGENT=0.7, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/04/c0c827a5-7320-46a1-ad97-21178a607ed6_20250304T17:41_UTC.wav
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[AGENT][POSITIVE] Thanks for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII] in Berker Resources. How are you today?
[AGENT][NEUTRAL] I'm good, [PII]. How are you?
[CUSTOMER][NEUTRAL] I'm pretty good. I have got a broker's office online. Her name is [PII], and she's calling about a possible claim for one of their insureds. Um, she just has some questions on what's, you know, a pay, you know, what if, what benefits are payable. sorry, couldn't get that spit out fast enough, um, and the policy that she's calling about is 248-6566 for [PII]. Would you be able to talk to [PII]?
[AGENT][NEUTRAL] Um, [PII] don't have any claims on file.
[CUSTOMER][NEUTRAL] Right, I said it's a possible claim she just has some benefit questions before he files the claim.
[AGENT][NEUTRAL] OK, let me verify if we have permission to speak with.
[AGENT][NEUTRAL] Bear with me, [PII].
[AGENT][NEUTRAL] You said her name was [PII]?
[CUSTOMER][NEUTRAL] Yes, [PII], she is with Acerer. She's with the broker's office.
[AGENT][NEUTRAL] OK. You can send her over. Did she verify his date of birth and everything?
[CUSTOMER][NEUTRAL] Uh, she had his name and policy, so I've got that much.
[AGENT][NEUTRAL] All right, so you can send over.
[CUSTOMER][POSITIVE] Thank you you have a great day.
[AGENT][POSITIVE] Thanks, you do the same.
[AGENT][NEUTRAL] Hello [PII].
[CUSTOMER][NEUTRAL] Yes, hi.
[AGENT][NEUTRAL] Could you verify [PII]'s date of birth? My name is [PII] and I'll be assisting you.
[CUSTOMER][NEUTRAL] OK [PII], you know what? I don't have his date of birth. Um, I just, let me see if there's, I can't remember if they're on the Ben admin, bear with me a second.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I just took a phone call from him. Oh, they are a navigator. Good. Hold on a second. It'll take me a minute to log in, but I can get it.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEGATIVE] And I'm just, he's very upset because the poor gentleman thought he went to an urgent care, but when he started sharing with me the amounts of the claims, I'm like, I think you ended up in a freestanding ER. And when he sent me the EOB from Cigna, sure enough, it was a hospital.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And here he's like, I put in urgent care when I was bleeding and driving to the urgent care.
[AGENT][NEUTRAL] Oh.
[CUSTOMER][NEGATIVE] So now he's very upset, but.
[CUSTOMER][POSITIVE] Hang on, I'm getting there.
[AGENT][POSITIVE] A good thing he has a gap insurance.
[CUSTOMER][NEUTRAL] Yeah, I just need to know how much uh it actually is gonna cover.
[CUSTOMER][POSITIVE] So I can at least hopefully give them some good news.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And hang on.
[CUSTOMER][NEUTRAL] I just have to get my authenticator code so I can get in and find him.
[CUSTOMER][NEUTRAL] I should have done that, but I thought since I'd already talked to the lady before that um
[CUSTOMER][POSITIVE] Uh well, no worries, I'm almost there.
[CUSTOMER][NEUTRAL] That's
[CUSTOMER][NEUTRAL] Here he is. [PII]. All right, his.
[CUSTOMER][NEUTRAL] His birthday's [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And you wanted to verify his outpatient benefits, correct?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, so it appears he has a bill from the emergency room in the amount of $3,034 and then he also has an invoice or a bill from the emergency room for physician for about $500. So will it cover any, will it cover the emergency room physician too or just the hospital?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] He has outpatient benefits, so to cover anything that was taking place in an outpatient setting.
[CUSTOMER][POSITIVE] Oh wonderful, OK.
[AGENT][NEUTRAL] Yup. So did anything go towards his deductible or co-pay?
[CUSTOMER][NEUTRAL] It all went to it. So he owes 3,034 to the hospital and 500 something to the um.
[CUSTOMER][NEUTRAL] To the emergency room physician.
[AGENT][NEUTRAL] It has outpatient benefits of $6600 per calendar year. This is not a guaranteed benefit it's just a disclaimer on the policy's coverage.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] OK, and that's the amount of deductible of 6600, so I have not really dealt with a gap plan before. This is my only group that has one, so I know that they file a claim with the gap plan. So are you saying that they should cover all of it?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, whatever went towards deductible, co-pay and co-insurance. If anything, if whatever that amount is, then that's what APL will cover for services that's covered under the policy.
[CUSTOMER][NEUTRAL] I mean I know it's
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][POSITIVE] Oh my gosh, that's wonderful. I need one of those plans.
[AGENT][NEUTRAL] Mhm. Me too.
[CUSTOMER][NEUTRAL] OK, all right, he will be so happy to hear this. So, uh, [PII] was sending the online access in the claim form, so all he needs is his ID number, his name, his date of birth, and, um, can you confirm.
[AGENT][NEUTRAL] I need the um
[AGENT][NEUTRAL] The EOB from the primary insurance company and then he would also need the diagnosis.
[CUSTOMER][NEUTRAL] I'm sorry?
[AGENT][NEUTRAL] For that date of service.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I think the diagnosis is probably on the EOB, but I'll have to look at it and see if it.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Oh, I didn't get the other email from him.
[AGENT][NEUTRAL] The diagnosis is gonna start with a letter and then maybe 2 numbers in a period and more numbers or just a letter and numbers.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yep.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] ICD 10. I used to work in medical, so I'm quite familiar, um.
[CUSTOMER][NEUTRAL] So how does he just have to get the ICD number well.
[AGENT][NEUTRAL] Does he need it in order for us to process the claim.
[CUSTOMER][NEUTRAL] OK, but he doesn't have to have something from the provider with it written he can just ask them what it is and get it from them, is that correct?
[AGENT][NEUTRAL] Um, no, he needs something from the provider showing the diagnosis codes, what he went for. Like he can call in and ask them for a, um,
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 1500 or UB?
[CUSTOMER][NEUTRAL] Yeah, it'd be a CMS 1500.
[AGENT][NEUTRAL] You can contact billing. Mhm.
[CUSTOMER][NEUTRAL] OK, so he needs the CMS 1500, the EOB.
[AGENT][NEUTRAL] And then he probably gonna have a UB for the physician charges.
[AGENT][NEUTRAL] He may have a UV or they may have a 1500. OK.
[CUSTOMER][NEUTRAL] No, UB's hospital.
[CUSTOMER][NEUTRAL] But since it's outpatient I think it it will be a CMS 1500 but yeah you'd be 90.
[CUSTOMER][NEUTRAL] Or did they change it to UBO2? I don't know. I can't remember.
[AGENT][NEUTRAL] So the 1500 will be, the extra will be the facility charges, but the majority of the claims that we received, if the physicians, the the um professional fees come on up, you'd be.
[CUSTOMER][NEUTRAL] No, outpatient professional would be a CMS 1500.
[AGENT][NEUTRAL] Uh process planes.
[CUSTOMER][NEUTRAL] Unless the hospital's billing form, so I don't know. Well, OK, either way I'll give him all of that and let him know, um.
[CUSTOMER][NEUTRAL] He can do it online or he can fill out the form and send in do you know about how long it takes to get reimbursed or are you gonna pay the providers directly or are you going to pay him directly?
[AGENT][NEUTRAL] So if he submits the claim on his on the behalf of them then it may go to him, but if the providers submitted the claim, then the payments are gonna definitely go to the provider if those some of the benefits are signed.
[CUSTOMER][NEUTRAL] So is it better for him than just to call them and tell them to submit the claim to you guys directly? It sounds like it is.
[AGENT][NEUTRAL] Yeah, he can um he can give them his information, his secondary insurance, but majority of the time when we receive a claim, the UB is gonna be for the facility charges and the $1500 is gonna be the professional fees with place of 1120, the place of service is gonna be 23.
[CUSTOMER][NEUTRAL] Yep.
[AGENT][NEUTRAL] So we need it from for each services.
[CUSTOMER][NEUTRAL] Right. That's OK.
[CUSTOMER][NEUTRAL] Right, right, nope, that makes sense and you said, and that is correct. The CMS 1500 is the outpatient side, and the UB is usually facility if I, I thought when it was outpatient the hospital might have built it on a 1500, but um anyways.
[AGENT][NEUTRAL] Oh, no, ma'am. They send us a lot of bills these days. When you go to the facility, it's the facility charge by itself if you've seen a radiologist, it's a radiologist bill by itself a professional fee for whomever did it, who did the radiology. Yeah, you get bills from multiple individuals these days.
[CUSTOMER][NEUTRAL] The UB
[CUSTOMER][NEUTRAL] Uh huh.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh huh.
[CUSTOMER][NEUTRAL] Right, right, that's where I came to radiology, so yeah, we were hospital based for a long time and we also had a free standing facility. So, OK, all right, well thank you so much for that. I, and I'm sorry, I didn't write your name down. What was your name?
[AGENT][NEUTRAL] My name is [PII].
[CUSTOMER][NEUTRAL] OK, thanks [PII] I appreciate the information. 01 more thing I did want to confirm his ID number is 2486566. Is that correct?
[AGENT][POSITIVE] That is correct, yes.
[CUSTOMER][POSITIVE] OK all right well I'm gonna recommend he try to get them to file the claim but if not then I'll have him file it and he will be thrilled to find out that the whole amount is gonna be covered so that's fantastic news. So thank you so much.
[AGENT][NEUTRAL] Yes, ma'am. Is there anything else that I can assist you with, [PII]?
[CUSTOMER][POSITIVE] No, that's it you have a great day.
[AGENT][POSITIVE] Thanks for calling APL. You have a great one as well. Goodbye.
[CUSTOMER][POSITIVE] Thank you bye bye.