AccountId: 011433970860
ContactId: e96ae54c-a839-4a4a-9672-23275d180ee8
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 629799 ms
Total Talk Time (AGENT): 262181 ms
Total Talk Time (CUSTOMER): 334588 ms
Interruptions: 6
Overall Sentiment: AGENT=0.8, CUSTOMER=-0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/04/e96ae54c-a839-4a4a-9672-23275d180ee8_20250204T19:20_UTC.wav
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[AGENT][POSITIVE] Good afternoon, thanks for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hey [PII], it's [PII]. How are you?
[AGENT][NEUTRAL] Fine, how are you?
[CUSTOMER][NEUTRAL] I'm all right thank you um other than I have a provider on the line.
[CUSTOMER][NEUTRAL] Questioning um with questions on the two claims we have on file for this member. The policy number is 255.
[CUSTOMER][NEUTRAL] 7447 for part one [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And they provide the lady on the line that I'm speaking with, her name is also [PII].
[CUSTOMER][NEGATIVE] But it's the two claims they're trying to get this member's information in their system correct. She said they had it everywhere. I mean it was all messed up.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] What kind of information is she?
[CUSTOMER][NEUTRAL] I've given
[CUSTOMER][NEUTRAL] She's got questions on like, well, I've got questions on this claim because it looks like we paid benefits to the insured.
[CUSTOMER][NEUTRAL] And to the provider on the same claim number.
[CUSTOMER][NEGATIVE] And I don't understand how we do that.
[CUSTOMER][NEUTRAL] On both of these claims.
[AGENT][NEUTRAL] Uh, let me look at them. Let me pull up one.
[AGENT][NEUTRAL] Let's see here.
[CUSTOMER][NEUTRAL] And of course, she doesn't.
[AGENT][NEUTRAL] In both claims it's for the same provider?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] But she doesn't know anything about that.
[AGENT][NEUTRAL] Hm
[AGENT][NEUTRAL] OK, so on this first claim that was paid out. So yes, any since we pay, it only covers the $75 indited amount since on the bill, they're charge amount for each CPT code, one line was only $18.01 line was only $11. So in that instance, it would be a split pay, we would only be able to pay the provider that only $29 and the difference of that benefit goes to the insured.
[AGENT][NEUTRAL] So that's why it was split pay that, that's why we only paid $29 to the provider because that was the total charge amount paid. I mean total, total, total charge amount that incurred from the provider and then the $46 was paid to the insured.
[CUSTOMER][NEUTRAL] OK. So, OK.
[AGENT][NEUTRAL] So which we will only address since it's the provider call and we will only let them know yeah.
[CUSTOMER][NEUTRAL] Right, you're only gonna correct and then she's got some questions on the number that she needs to use that they need to have in their system for this number because she's saying this lady also is Medicare Primary.
[CUSTOMER][NEUTRAL] And I told her that this is a separate, you know, this is not a major medical insurance. This is a hospital indemnity limited benefit plan.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right.
[AGENT][POSITIVE] Mhm. Yeah, that's correct.
[CUSTOMER][NEUTRAL] But as far as how they need to enter it or you know, because like 99.9.5% of these people who have our coverage and IMA only have a card that has that ID number for IMA, not APL cards.
[CUSTOMER][NEUTRAL] So what number does she need to use when filing a claim? That's one of them. She has IMA's address, but does she need to use the.
[AGENT][NEUTRAL] Yeah, yeah.
[CUSTOMER][NEUTRAL] The D number or does she need to use our policy?
[AGENT][NEUTRAL] So yeah, claims, yeah, claims will all go to yeah, claims will always go to IMA. You'll give them that mailing claims address, but it will be our policy number, which is listed on the.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Card that was issued as well.
[CUSTOMER][NEUTRAL] Yeah, but they don't ever have that card.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] Because we don't mail these automatically, so that's all these, these policies are a nightmare is what they are.
[AGENT][NEUTRAL] So it would be our
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] They're a nightmare.
[AGENT][NEUTRAL] So I can help her if you want to transfer her to me. But yeah, yeah, it would be our policy number that she would use to input it um for her coverage with us.
[CUSTOMER][NEGATIVE] Oh, no.
[CUSTOMER][NEUTRAL] OK, I think [PII], I mean, I was just gonna join her and I wasn't gonna release the call just to hear how you explained it to her again I haven't mentioned anything about, you know, seeing that part of the benefits were paid. No, I haven't mentioned any of that. um, it was just like it's that threw me but as far as entering in the system and verifying which number I explained to her that IMA that is the correct address because it goes to their clearing house.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] How those payments were paid to the, yeah.
[CUSTOMER][NEUTRAL] Before you know it comes to us, which is correct, right? OK, alright, so I just want to, yep, so if you'll just kinda I guess then just validate what I said and then let she ask you something else.
[AGENT][POSITIVE] Correct. Mhm. Yeah, that's correct what you told her.
[CUSTOMER][NEUTRAL] That I'm, that I don't know she's gonna ask you, but I'm gonna stay on the line.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, that's fine. And what was her name?
[CUSTOMER][NEUTRAL] OK, so let me join her in her name is also [PII], same as the insured.
[AGENT][NEUTRAL] Oh, yeah, that's right, you did say that.
[CUSTOMER][POSITIVE] OK, so hold on just a minute. Thank you very much for doing this.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Hi [PII].
[CUSTOMER][NEUTRAL] Yes. This is still [PII] and I have one of our examiners on the line with us. [PII], can you also hear us?
[AGENT][NEUTRAL] Yes, I can hear you.
[CUSTOMER][NEUTRAL] OK, so I'm gonna let um let you speak with [PII], but I have given her some of the background on on our call and that you're just trying to get your system information straight, um, and so she's just gonna verify some of the information that I've already given you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, [PII]. OK.
[AGENT][NEUTRAL] Hi, [PII].
[AGENT][NEUTRAL] So you, you would need to verify exactly which policy number you're needing to utilize in your system when filing a claim with us?
[CUSTOMER][NEUTRAL] Well, originally we were sending it to the 90 degree plan with that ID number, but the claim ended up being I guess dispersed she had stated at the clearing house to y'all, so that works out um but yes I mean do we need to put it in the system underneath the APL with y'all's ID number and not 90 degree with their ID number?
[AGENT][NEUTRAL] So on the claim um form it looks like, yeah, it looks like on the claims you have filed, it looks like, yeah, they do have a multi-plan, so they do have a different member ID number as far as filing the claims, um, you can utilize our policy number.
[AGENT][NEUTRAL] When filing a claim
[AGENT][NEUTRAL] Through the clearinghouse as well. So if you submit the claim, you would use our policy number, which is the 02557447.
[CUSTOMER][MIXED] OK, but still send the claims to that PO box?
[AGENT][NEUTRAL] Correct. So you will still need to file the claim with the [PII].
[CUSTOMER][NEUTRAL] OK, so I will expire the other plan then and add this one because the other rep said that the 90 degree plan ended in January of.
[CUSTOMER][NEUTRAL] She was transferred to us [PII] by IMA and they said that policy termed for them 15, but I explained that our policy is still active.
[AGENT][NEUTRAL] OK. Yeah, looks.
[AGENT][NEUTRAL] Yes, it is still active, effective [PII].
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Um, and the other question is we filed these two claims, 2 dates of services.
[CUSTOMER][NEUTRAL] To y'all
[CUSTOMER][NEUTRAL] But it should have been sent to Medicare Primary because the patient has Medicare. We just were unaware at the time that her Medicare is her primary coverage.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Do we need to refund you all these?
[AGENT][NEUTRAL] OK. So if for that instance, since this is not um our coverage is only a, a hospital indemnity plan and it, and from the information that was submitted to us, it looks like it was assignment of benefits. So that's why benefits were paid directly to you. Um if benefits were already paid by their other insurance carrier and um then benefits will be due to the patient, then you, then yes, we would need a refund in order to disperse the benefits to the insured directly.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] If they, if they've already been paid by their other insurance carrier.
[CUSTOMER][NEUTRAL] No, we haven't billed it yet we were gonna do that today um I'm just trying to figure out what we need to do with the money from y'all on these claims.
[AGENT][NEUTRAL] So you have not filed the claim yet with their other insurance, correct?
[CUSTOMER][NEUTRAL] Right, that is happening today that's why I wanted to call because we were unaware of the situation.
[AGENT][NEUTRAL] OK, so
[AGENT][NEUTRAL] OK, so you don't know what they're gonna cover or not cover at this time then. OK, so then I would advise once those claims are filed with them and you get the claim decision and if those claims were not covered by their other insurance, then the, you wouldn't owe us anything that you wouldn't send us a refund.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] But if they pay the amount in full, then at that time, we can um.
[CUSTOMER][NEUTRAL] OK,
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] You can return those funds to us and we can re um distribute those funds to the insured at that time.
[CUSTOMER][NEUTRAL] OK, and if any is out, let's say for example Medicare on their EOB states that the patient owes co-insurance or deductible.
[CUSTOMER][NEUTRAL] Would we use the money that y'all sent for these to cover that and then call back and see what the difference would be or or how does that is that what I need to do? OK.
[AGENT][NEUTRAL] Yes, yes, that is correct. Yes, we will need, you would just need to submit us with that EOB and we can reprocess the claim according to that primary EOB from Medicare.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, all right.
[CUSTOMER][NEUTRAL] I think that's all the questions I have then um what is y'all's phone number instead of me going through 90 Degree?
[AGENT][NEUTRAL] Sure, our number is [PII].
[CUSTOMER][NEUTRAL] Bye.
[CUSTOMER][NEUTRAL] All right, and I think um if I could just get a reference number for the call.
[AGENT][NEUTRAL] It'll be just my name and that's [PII] and that's [PII] today's date. Is there anything else I can assist you with today, [PII]?
[CUSTOMER][NEUTRAL] That's it.
[AGENT][POSITIVE] OK, well thanks for calling APO you have a good day.
[CUSTOMER][POSITIVE] Alright thank you both so much. Alright. Thank you both. Thank you. All right, you're welcome, [PII].
[AGENT][POSITIVE] You're welcome. Bye.
[CUSTOMER][NEUTRAL] Bye bye.