AccountId: 011433970860
ContactId: e25a983d-e17f-4272-9a9f-80c177956358
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1006380 ms
Total Talk Time (AGENT): 293634 ms
Total Talk Time (CUSTOMER): 560514 ms
Interruptions: 11
Overall Sentiment: AGENT=0.6, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/17/e25a983d-e17f-4272-9a9f-80c177956358_20250417T17:30_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling ATL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII] in Broker Resources. Can I give you a policy number? I've got a broker on my other line. He's calling on this Medlink policy. Um, they submit the broker submitted on behalf of the patient, and he says it's been processed, but I told him he can't see the end result. So I was trying to get the status on it. Can you give, can I give you the policy number?
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Yeah, absolutely, go ahead, [PII].
[CUSTOMER][NEUTRAL] OK, it is 2606687 for [PII] and that's how you say her name.
[AGENT][NEUTRAL] OK, let's see here.
[AGENT][NEUTRAL] OK, and then who are we talking to on the line?
[CUSTOMER][NEUTRAL] Um, it is, give me a second, [PII]. He's the account, um, the agent on record for this group.
[AGENT][NEUTRAL] OK, and then did we get a call back or anything?
[CUSTOMER][NEUTRAL] I have a callback number for him. It's [PII].
[AGENT][POSITIVE] Alright, awesome. You can go ahead and send him over, [PII].
[CUSTOMER][NEUTRAL] OK, I'll pull him on the line. Give me just a second.
[AGENT][POSITIVE] OK, no problem.
[CUSTOMER][NEUTRAL] Hi, um, [PII], I've got one of our customer care people on the phone that's gonna help you with that that claim status and let you know what's going on with it. Did you have any other questions for me?
[CUSTOMER][POSITIVE] Uh, no, no, just give me a call back when you know about the ID cards. That was it, yeah, I appreciate it. OK, OK, no problem, you have a great day. Thank you. Talk to you soon bye bye. Alright.
[AGENT][NEUTRAL] Hi, [PII]. My name is [PII] in customer care. I just need to verify the insured's name and date of birth, please.
[CUSTOMER][NEUTRAL] Sure that would be um [PII] um her date of birth here do I gotta go somewhere else to look for um.
[CUSTOMER][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] That's not on her profile, huh? And the last four of the social is [PII], but um.
[CUSTOMER][NEUTRAL] Uh, anywhere here.
[CUSTOMER][NEUTRAL] No, it's not on the APL, right? Right, it doesn't show me right in the portal for birthday.
[AGENT][NEUTRAL] Oh, no, it may not.
[AGENT][NEUTRAL] Do you have a claim number that you're checking on or was it just recently submitted?
[CUSTOMER][NEUTRAL] I mean I don't.
[CUSTOMER][NEUTRAL] Yeah, it was just recently submitted it says processed.
[CUSTOMER][NEUTRAL] Um, yeah, mhm.
[AGENT][NEUTRAL] It does say processed?
[AGENT][NEUTRAL] OK, let me see.
[CUSTOMER][NEUTRAL] The
[CUSTOMER][NEUTRAL] You there?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Was it under the secondary policy?
[CUSTOMER][NEUTRAL] Yeah, the, the medlink.
[AGENT][NEUTRAL] Medlink, OK.
[CUSTOMER][NEUTRAL] Yeah, leave a message.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Sure
[CUSTOMER][NEUTRAL] I wasn't on the terms of the either so I didn't have like.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] OK, it doesn't look, it must have been what was, do you know what the date of service was because her active policy doesn't show any claims. It may be the one.
[CUSTOMER][NEUTRAL] too.
[AGENT][NEUTRAL] Because it looks like the policy number changed in March.
[CUSTOMER][NEUTRAL] I see. I have a confirmation number. I have, yeah a confirmation number.
[CUSTOMER][NEUTRAL] that will help you have a policy number you want that you said?
[AGENT][NEUTRAL] Um, what's the confirmation that you have?
[CUSTOMER][NEUTRAL] Or claim or the claim number or the claim number.
[AGENT][NEUTRAL] Claim num yeah, claim number will work too.
[CUSTOMER][NEUTRAL] OK, 358-577-72.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, that's
[AGENT][NEUTRAL] On the older one
[CUSTOMER][NEUTRAL] I know some of the problem might be because like you said, the policy did change in March, but the claims that they'll be submitting, you know, were from before March.
[AGENT][NEUTRAL] Right. OK.
[CUSTOMER][NEUTRAL] What
[AGENT][NEUTRAL] So this claim shows that the insured's primary provided full benefits, so there was nothing for us to provide.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEGATIVE] I mean she's getting a bill though.
[AGENT][NEUTRAL] It was
[AGENT][NEUTRAL] Mm.
[AGENT][NEGATIVE] It was declined showing.
[CUSTOMER][NEUTRAL] That's what I said.
[AGENT][NEUTRAL] Primary insurance provided full benefits and it was processed on the [PII], it looks like.
[CUSTOMER][NEUTRAL] Why is she getting a bill for like
[CUSTOMER][NEUTRAL] You know, $155 emergency room physician.
[CUSTOMER][NEUTRAL] I mean, I'm looking at the ELB here.
[AGENT][NEUTRAL] Let me see what was submitted on this. Give me a second.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] I imagine you guys.
[CUSTOMER][NEUTRAL] Yeah Medicaid, Medicare, the.
[CUSTOMER][NEUTRAL] Which is
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Last but not least, what your annual income yearly is 1,600,020, 25, 30, whatever is it.
[AGENT][NEUTRAL] So it looks like it shows deductible co-pays amount they're all 0.
[CUSTOMER][NEUTRAL] Ok.
[CUSTOMER][NEUTRAL] You said [PII]?
[AGENT][NEUTRAL] On this EOB that I'm pulling up.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] There is nothing for us to apply towards that cause that's what this is gonna cover, you know, is deductible, co-pay, co-insurance.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] I don't see coin insurance on that EOB. I see deductible and copay.
[AGENT][NEGATIVE] I see deductible and copay all 0 looks like the.
[AGENT][NEUTRAL] Examiner highlighted. Let me go back up.
[CUSTOMER][POSITIVE] Thank you on for a second.
[CUSTOMER][NEUTRAL] Card, C [PII] Last name [PII] Date of birth is [PII]. Not when it says 14,930 has been deducted from the provider's payment for withholding. This is not, this amount is the responsibility of the patient.
[CUSTOMER][NEUTRAL] But it does look like you qualify for a subsidy amount of $588.94 a month to be that OK.
[CUSTOMER][POSITIVE] So the way this coursese your preventive care will also be covered 100% out of [PII] after there's no charge, specialist can be no charge, zero deductible, zero premium, and like I said, you qualify for 5888 and 94 cents a month, OK travels.
[CUSTOMER][NEUTRAL] What is gonna be the best address to know your parking?
[AGENT][NEUTRAL] Wondering if
[CUSTOMER][NEUTRAL] [PII]?
[AGENT][NEUTRAL] Yeah, cause everything that I see that the examiner's gone through is just highlighting this.
[AGENT][NEUTRAL] Deductible and co-pay that there's zero, so I'm thinking that that's why the denials reading the primary insured provided full benefits, there was nothing for us to pay.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] If you go down a little bit, it's saying that like 14,930 has been deducted from the provider's payment for withholding.
[CUSTOMER][NEUTRAL] This amount is the responsibility of the patient. Can you hear any problems? It's like page 4 or 6 on that, on the things I uploaded.
[CUSTOMER][NEUTRAL] I mean you'll be.
[CUSTOMER][NEUTRAL] I was on the first page too. 467614438
[CUSTOMER][POSITIVE] OK, I'm gonna read you over 10 disclosure questions. [PII], these are all gonna be yes or no questions. So whenever you're ready, let me know so I can read this to you one by one.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, all right. Let me
[CUSTOMER][NEUTRAL] Alright, can you verify that your annual income will be around 16,000 and if any changes to the income when you by yourself, OK.
[AGENT][NEUTRAL] Double check with an examiner on it and make sure and see if there's something else that we need or if it was just not processed correctly on their end. Do you mind holding the line, Cortland, one second.
[CUSTOMER][NEUTRAL] All right. Do you have any major medical, um, do you have any major upcoming surgeries or procedures scheduled at the moment or no? Sure, sure, no, no, of course.
[AGENT][POSITIVE] Thanks.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Deferring
[CUSTOMER][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How may I help you?
[AGENT][NEUTRAL] Hi, this is [PII] over in customer care. How are you doing today?
[CUSTOMER][NEUTRAL] Doing well, [PII] how are you?
[AGENT][NEUTRAL] I'm doing all right. Um, I have a broker on the line. He's the contact for
[AGENT][NEUTRAL] A group. Anyway, he's checking on an insured's claim that was denied and I was reading the denial to him and
[AGENT][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.
[CUSTOMER][NEUTRAL] Sure, what's the policy number sir?
[AGENT][NEUTRAL] Uh, policy number is 015.
[AGENT][NEUTRAL] 24159.
[AGENT][NEUTRAL] And it's for uh [PII].
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] OK, and it's Medlink. OK. And is it that last claim process the ending in 772.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh yes, ma'am. Uh-huh, yeah.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And so I did see like on the EOBs that they submitted, it looks like it was, you know, highlighted the deductible co-pays 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?
[CUSTOMER][NEUTRAL] I'm pulling it up now.
[AGENT][POSITIVE] No, no worries.
[AGENT][NEUTRAL] I'm new to all this still, so trying to figure it out, yeah.
[CUSTOMER][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.
[AGENT][POSITIVE] No, no, I appreciate you.
[CUSTOMER][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.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Let me look at the other.
[AGENT][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] OK, these meddling policies are very specific as to um what's covered #1 and #2, it's strictly co-pay 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.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Right.
[CUSTOMER][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 co-insurance and or deductible that's due for the EOBs now um.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK.
[AGENT][NEGATIVE] Gotcha.
[CUSTOMER][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.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Right, right.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] No, I, like, 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'd explain it well to them cause I was like, well, you know, there's no deductible, co-pay or co-insurance 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 co-insurance showing, you know, I, I didn't get that, so.
[CUSTOMER][NEUTRAL] Do you have a question?
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] Yeah, and these obese doesn't really explain to why it shows patient responsibility. Sometimes they get a little bit more detailed, but these don't have any kind of detail. Now it does give us a message here. Let's see if this helps us.
[AGENT][NEUTRAL] Right, OK.
[CUSTOMER][NEUTRAL] Because sometimes there's an explanation.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And I just saw it on one of these.
[CUSTOMER][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 be billed by the provider of service because they have a deductible or co-insurance or the service is not covered by the health plan.
[AGENT][NEUTRAL] Right.
[CUSTOMER][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 med link plan doesn't pay that service.
[AGENT][NEUTRAL] OK.
[CUSTOMER][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.
[AGENT][NEUTRAL] OK. All right.
[CUSTOMER][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?
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Well.
[AGENT][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.
[CUSTOMER][NEUTRAL] Certainly [PII]. Now, um, everything's been verified for the patient.
[AGENT][POSITIVE] Yes ma'am, I did verify him again. I got him from Broker Resources bless his heart.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Got you.
[CUSTOMER][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.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK, thank you.
[AGENT][POSITIVE] Thank you, 1 2nd.
[CUSTOMER][POSITIVE] You're welcome sir have a good day if I don't speak with you again.
[CUSTOMER][NEUTRAL] Hello? Hello [PII].
[CUSTOMER][NEUTRAL] Yup.
[CUSTOMER][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 claim for Ms. uh, [PII], I think it is [PII]. Sure, 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.