AccountId: 011433970860
ContactId: ebc305fb-5589-4dff-86d4-c096ee0eae94
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 263429 ms
Total Talk Time (AGENT): 131901 ms
Total Talk Time (CUSTOMER): 90937 ms
Interruptions: 0
Overall Sentiment: AGENT=0.8, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/24/ebc305fb-5589-4dff-86d4-c096ee0eae94_20250224T18:51_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII]. I'm calling from Hedryford Hospital to get the clarification on a claim.
[AGENT][NEUTRAL] OK, can I help you, [PII], what's the policy number and the claim number?
[CUSTOMER][NEUTRAL] OK, so the member's policy number is 02341145.
[CUSTOMER][NEUTRAL] And uh the claim number, one moment.
[CUSTOMER][NEUTRAL] The claim number is 3507852.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] And the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Patient's name is [PII], and date of birth [PII].
[AGENT][POSITIVE] OK, thank you for that information.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And you said that you needed clarification on claim number 3507852?
[CUSTOMER][NEUTRAL] Um, yes.
[AGENT][NEUTRAL] Did you receive an explanation of benefits from American Public Life?
[CUSTOMER][NEUTRAL] Yes, we did. So I can see the uh claim is requesting for uh the primary UOP. Is that correct?
[AGENT][NEUTRAL] Um, on the explanation on the back of it, it says that benefits are payable only if your major medical insurance provider provides benefits. So it sounds as though they denied the primary insurance denied the claim. So if this claim is later paid by the major medical insurance carrier, then you know the this office can send us a copy of the corrected explanation of benefits for review. So did they deny the charges in full?
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] No, they did pay it in full. There is no denial.
[AGENT][NEUTRAL] OK, and what's the date of the, um, so is that a corrected ELB maybe that you're looking at or is that the initial ELB?
[CUSTOMER][NEUTRAL] Uh let me just confirm
[CUSTOMER][NEGATIVE] No, it is the initial EOB. The only UOB we are having from primary is actually it's got partially paid and partially denied.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] Give me a second.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And what were the total charges?
[CUSTOMER][NEUTRAL] Um, one moment, $2,421 even.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] And you'll only process the primary's patient responsibility, right? You will not process the denial from primary.
[AGENT][NEUTRAL] Only the amounts if you look at the EOB, the deductible co-insurance, co-pay columns, are there anything in those columns any dollars in those columns, is it, does it show 0?
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEGATIVE] Um, yeah, actually there was a payment and then there was a denial. There is no deductible, co-pay or co-insurance.
[AGENT][NEUTRAL] And so, uh, the Metlink policy is a is secondary to the major medical. Our reimbursement is based on the information uh listed in the deductible co-insurance and co-pay column, which it shows 0.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] And so when you look at the denied reasons, it said it was denied.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Um, charges not qualify for ER urgent care and charges exceeds fee schedule, so you may want to contact, um, Blue Cross Blue Shield for clarification on the explanation of benefits, but as far as our position because there's nothing applied towards that deductible co-insurance or co-pay column, then it's considered not covered, therefore we would not pay it and it shows denied as well.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK then, I get it. Uh, so thank you so much for the clarification. I really appreciate it. And um, what will be your call reference number?
[AGENT][NEUTRAL] You'll use my name in today's date as your reference. [PII], [PII] initial last name is [PII], and any other questions I can help out with today?
[CUSTOMER][POSITIVE] Uh, I guess not on yeah. Uh, I'm good. So thank you so much for your assistance and you have a great day.
[AGENT][POSITIVE] You're welcome. Thanks for calling APL. Have a good day.
[CUSTOMER][POSITIVE] And thank you bye bye.