AccountId: 011433970860
ContactId: ce4f402c-e231-40cc-98c1-1f3acd840231
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 497559 ms
Total Talk Time (AGENT): 220383 ms
Total Talk Time (CUSTOMER): 226575 ms
Interruptions: 1
Overall Sentiment: AGENT=0.9, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/05/ce4f402c-e231-40cc-98c1-1f3acd840231_20250605T16:59_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], I have, uh, [PII] on the line. He has a question about group number 26904.
[AGENT][NEUTRAL] OK, um, and, um, I guess I'm so sorry. Are you, are you the broker?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Yeah, go ahead.
[CUSTOMER][NEUTRAL] I'm with the APL care. I'm with the care team at APL sorry I.
[AGENT][NEUTRAL] OK, OK.
[AGENT][POSITIVE] No, you're good.
[CUSTOMER][NEUTRAL] He said I sounded like I'm from [PII] so I was like it threw me off.
[AGENT][NEUTRAL] And so,
[AGENT][NEUTRAL] OK, so, um, he, he's calling about that group and is he the broker or is he the group or who, who is he?
[CUSTOMER][NEUTRAL] He is the broker for that group. He's wanting information uh he doesn't have the, the patients, uh.
[CUSTOMER][NEUTRAL] Account number um but I guess a hospital denied a patient services saying that we won't pay for it and he, he told me that I guess a member of someone from APL told him or told the insured or the the medical group that we won't pay for services but he's unable to find that that patient's um policy number.
[CUSTOMER][NEUTRAL] Uh, but I was told for a broker to, to transfer to broker resources because he's needing next steps on how to handle this situation.
[AGENT][NEUTRAL] Yeah, I might ask if you can take him to a claims because I have no idea about how claims are paid or or or anything like that. I don't know why uh uh anything would be declined.
[CUSTOMER][NEUTRAL] OK, so you don't want me to send them to you, you want me to send them to claims?
[AGENT][NEUTRAL] Here I'll if you wanna send them to me and then I can send them the claims that works too.
[CUSTOMER][NEUTRAL] OK, and then maybe he'll be able to to give you more information that might be more helpful. I was just told send brokers to broker resources for issues um regarding this, mhm.
[AGENT][POSITIVE] Yeah, absolutely.
[AGENT][NEUTRAL] Yeah, if it, yeah, a lot of times if it's like claims that I have, I have no idea on that. So, um, we just send them to claims just because a lot of times they're they're asking a specific thing and I'm not very helpful with that.
[CUSTOMER][NEUTRAL] OK, OK, um, I will transfer him over to you, um, and if you need to transfer him to claims, uh, we'll get it done somehow.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK, sounds good.
[CUSTOMER][POSITIVE] Alright, thank you so much. And your name is [PII]?
[AGENT][POSITIVE] Yeah, absolutely.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, I'll introduce you just give me a moment.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Hi [PII], are you still there?
[CUSTOMER][NEUTRAL] I am still here.
[CUSTOMER][NEUTRAL] Hey, I have [PII] from our broker resources who may be able to help you. If not, um, we might end up having to transfer you to claims. They might have more information for you, um, but if you could go ahead and let her know I gave her a brief synopsis of what you had mentioned to me first. I just wanna make sure we get you to the right person, OK?
[CUSTOMER][POSITIVE] Got you. Thank you.
[AGENT][NEUTRAL] Hi [PII], how are you?
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] I'm good [PII], um.
[CUSTOMER][NEUTRAL] So I've got a client who tried to go to get a procedure done this morning, outpatient procedure, ended up not getting it because the doctor's office wasn't understanding, uh, [PII], and then she, she called APL and she kind of got an odd response that she was told she would have to pay for it ahead of time.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Which I don't think that's true. Um, for a doctor who doesn't understand how to process this.
[CUSTOMER][NEUTRAL] Do they, what should they do if they.
[CUSTOMER][NEUTRAL] Obviously, it's probably the newest employee they have and they put them up front to take information. Um, they've got their APL card and everything like that. What, what should we get them to do? Just give them a number to call or just direct them on how to do that or what?
[AGENT][NEUTRAL] Yeah absolutely let me put you on a brief hold, OK? And then I'm, I'm just gonna do some research on this, OK?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Huh
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, so I have a broker on the line and he said that, how do we go about claims? Doesn't the, doesn't it happen like the, the surgery happens and then whatever, like it goes through major medical and then whatever isn't paid goes to us. So we don't pay upfront anything.
[AGENT][NEUTRAL] OK.
[AGENT][NEGATIVE] Because I have a feeling I was the person that the Integris Hospital called and I said, we don't pay for it, we paid for it after it's gone through major medical.
[AGENT][NEUTRAL] OK, OK, that's what I just wanted to make sure. And then he was asking if his client gets declined at the doctor's office, who does he call?
[AGENT][NEUTRAL] I guess the kind of they they decline them like do I give them customer service or
[AGENT][NEUTRAL] they don't they can file a claim.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, but they to file a claim then they go on and fill out that form, submit it through the portal or mail it in or fax it.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Hey [PII], are you still there?
[CUSTOMER][NEUTRAL] I'm still here.
[AGENT][NEUTRAL] OK, perfect. So how our insurance works is we are a supplemental insurance, so it has to go through like the claim has to go through the major medical first and then once it
[CUSTOMER][POSITIVE] Right, yeah, I've sold a ton. I've sold a ton of ton of med link. I've just never had any trouble with it before.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] So the reason it was declined is because it has to go through major medical and then whatever they don't pay, then it will come to us and we will pay it. Um, we just need like an, an EOB or um something afterwards like it, it doesn't get billed to us through the carrier.
[AGENT][NEUTRAL] And so then to to file a claim then after they receive the remainder bill from the hospital, then they would submit a claim form which you can find on our website or through our portal and then they would submit that and that's how it would get paid.
[CUSTOMER][NEUTRAL] Right, so
[CUSTOMER][NEUTRAL] So APL has always told us whenever a member goes to receive services, they need to show both cards, their major medical card and their APL card.
[CUSTOMER][NEUTRAL] And then that's the last they touch it.
[AGENT][NEUTRAL] Yeah, they, they can. It's, it, it is though that they have to submit a claim. It's not like it's like major medical where it pays and then it gives you a bill for what's remaining for you. Um, it's, it's after the major medical has paid for it, then it goes to us. So like say it was a $700.
[AGENT][NEUTRAL] Uh, procedure, Major medical is only paying $400 of it. The patient gets a bill for $300 then the patient would submit that $300 remaining bill to APL to see if we would pay for it.
[CUSTOMER][NEUTRAL] Um, OK, that, so I've been selling APO for years and the only thing we've ever told our clients and nobody's ever said a word about it.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] is they give both cards to the doctor and the doctor, not necessarily at the same time, but they, they, they do file both claims. So my understanding was
[CUSTOMER][NEUTRAL] APL is going to send
[CUSTOMER][NEUTRAL] Kind of a kind of a different type of EOB to the provider.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Yeah, I've never heard of this. I've never heard that the employee has to take anything on themselves to submit a manual claim.
[AGENT][NEUTRAL] OK, um, do you want me to, to have someone on our claims department maybe they are aware of something different than I am.
[CUSTOMER][NEUTRAL] Yeah, let me, um, let me call. I'm gonna call [PII]. He's our GA I'm gonna call him. He'll he'll, I'm sure he'll help me, um, OK, thank you.
[AGENT][POSITIVE] OK, sounds great.
[AGENT][POSITIVE] OK, sounds great, of course, bye.
[CUSTOMER][NEUTRAL] OK, bye bye. Oh.