AccountId: 011433970860
ContactId: f8b010f9-1f31-4dcf-8973-c717ab6c1aa9
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1387280 ms
Total Talk Time (AGENT): 334599 ms
Total Talk Time (CUSTOMER): 285005 ms
Interruptions: 3
Overall Sentiment: AGENT=0.3, CUSTOMER=-1.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/20/f8b010f9-1f31-4dcf-8973-c717ab6c1aa9_20250320T14:36_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Uh, hi, this is [PII]. I'm calling from the business office of Valley Baptist Medical Center on a recorded line, and I just need to follow up on a bill that we have submitted.
[AGENT][POSITIVE] OK, well, I'll be more than happy to help you with the claim status and Regime, may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] That would be [PII] and it's a direct line?
[AGENT][NEUTRAL] Thank you for that. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] That would be 01868783.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] I have [PII], and date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And may I have the data service for the claim you like me to check on?
[CUSTOMER][NEUTRAL] Mhm. I'm looking for [PII].
[AGENT][NEUTRAL] OK, and the total, the total bills?
[CUSTOMER][NEUTRAL] That would be 90, I'm sorry, $99,071 even.
[AGENT][NEUTRAL] OK, so [PII] $99,0071?
[CUSTOMER][NEUTRAL] Just
[CUSTOMER][POSITIVE] Yes, that's correct.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] And what is the name of the facility on the claim?
[AGENT][NEUTRAL] Hello [PII].
[CUSTOMER][NEUTRAL] That would be under Well Baptist Medical Center or Brownsville Hospital.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] So I'm showing the claim was received on [PII].
[AGENT][NEUTRAL] The claim number is 355.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I'm sorry, I did cut you off. I'm actually thinking if you can help me check the appeal that we have submitted dated [PII].
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] OK, so
[AGENT][NEUTRAL] What, what was received on [PII], that's claim number 356-8124.
[AGENT][NEUTRAL] And on [PII], it was denied as miscellaneous correspondence from the insured.
[AGENT][NEUTRAL] And or provider?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] But the max for the benefit was used for the paid claim. So what is the year to appeal?
[CUSTOMER][NEUTRAL] So, um, right now, I am thinking if, uh,
[CUSTOMER][NEUTRAL] Since we are trying to
[CUSTOMER][NEUTRAL] Bill the secondary insurance, uh, which is the American Public Life. And we have already an expected reimbursement for that, which is the patient's responsibility of the primary insurance. So, technically, uh, we are expecting an additional payment of 2,33648 cents. However, it seems that we are getting the notification here that the secondary insurance was supposed to
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, process this claim is out of network. However, on your
[AGENT][NEUTRAL] OK, wait, wait, wait, hold on one second.
[CUSTOMER][NEUTRAL] Explanation of benefit. It seems that the benefit
[AGENT][NEUTRAL] Hold on one moment. So this is the secondary insurance. There is no in or out of network. There are benefits for primary and there's benefits for us as secondary. For their secondary insurance, their inpatient calendar year max is 2550.
[AGENT][POSITIVE] dollars. So no matter what the total of the bill was that was sent to us, the max that this policy can pay, the maximum amount that this policy can pay is $2550 and we paid you that full amount. So we have given you the all that they have for the year.
[AGENT][NEUTRAL] They've used their funds on your claim. The max has been paid.
[CUSTOMER][NEUTRAL] Which is why we submitted an appeal for the underpayment that we're expecting to be paid.
[AGENT][NEUTRAL] So when a policy.
[CUSTOMER][NEUTRAL] But you're suggesting that we don't have a bill, right?
[AGENT][NEUTRAL] No, no, you have the right to an appeal. I'm just letting, I'm giving, I'm informing you. I'm educating you on this claim. If the, if the policy has a maximum amount that it can pay out, it can't pay more than its max.
[AGENT][NEUTRAL] Which is what we pay to you. So if the
[CUSTOMER][NEUTRAL] I understand that which I was explaining earlier, uh, since we're expecting this to be processed out of network, but you're giving this a denial as well for benefit maximum. So I would like to confirm which of these two things that we need to appeal the underpayment or this benefit maximum. But since, so you mentioned that there are missing documentation for the appeal that we have submitted.
[AGENT][NEUTRAL] No, we received the documentation that you that you submitted. It was, it was just miscellaneous, it was just miscellaneous documents. That was the denial reason on the claim.
[AGENT][NEUTRAL] But we can't process it as out of our policy doesn't have out of network benefits. It just has a set amount that we will pay for the year or calendar day.
[CUSTOMER][NEUTRAL] That's what I just need to confirm that this claim was really processed as.
[CUSTOMER][NEUTRAL] Either in network or out of network.
[AGENT][NEUTRAL] In or out of network, we do not have in or out of network benefits. We are a secondary insurance company. We do not have in or out of network benefits. We have inpatient.
[CUSTOMER][NEUTRAL] So we still have.
[AGENT][NEUTRAL] An outpatient and an amount that we will pay. The amount that we will pay has been paid to you in full.
[AGENT][NEUTRAL] We cannot go over the maximum that a policy will pay.
[CUSTOMER][NEUTRAL] So how many apps we can send for the benefit maximum?
[AGENT][NEUTRAL] I don't understand your question. Um, so when you say how many appeals for the benefit maximum appealing what we've already, because we've already given the benefit maximum, so I don't know how to.
[AGENT][POSITIVE] You can appeal as many times as you like.
[AGENT][NEGATIVE] But for the benefit maximum, I don't understand that part because we've already paid the benefit maximum to you.
[CUSTOMER][NEUTRAL] Well, technically you mentioned that we are in at and since you mentioned as well that this is a secondary insurance.
[CUSTOMER][NEUTRAL] Processing and you're not processing it as out of network or in network.
[CUSTOMER][NEUTRAL] Then we are just appealing the denial on the claim. Well, technically it's a benefit maximum for us.
[AGENT][NEUTRAL] So [PII], do you have a supervisor that maybe I can speak with to explain this to?
[CUSTOMER][NEUTRAL] I totally understand what's happening on this claim. I just need to verify and confirm what needs to be done on this account.
[AGENT][NEUTRAL] There is nothing that can be done if you're asking for the, what can be done in terms of the patient responsibility with the secondary insurance, we don't determine that. In terms of an appeal for the claim with APL, you can appeal as many times as you like, but we've already paid out the calendar year max for this policy to you.
[CUSTOMER][POSITIVE] Exactly.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][POSITIVE] Yeah, exactly.
[AGENT][NEUTRAL] So do you have a supervisor that maybe I can uh
[CUSTOMER][NEGATIVE] We cannot appeal this out of network and we cannot even.
[CUSTOMER][NEUTRAL] Maybe you can transfer me to your supervisor that I can also relay the information that we need to do on this account.
[AGENT][NEUTRAL] May I speak with your supervisor, please?
[CUSTOMER][NEUTRAL] Maybe you can transfer me to your supervisory instead.
[AGENT][NEUTRAL] Ma'am, I've, I've requested to speak to your supervisor so that I can assist.
[CUSTOMER][NEUTRAL] Uh, no, I am also requesting a manager.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] On your end.
[AGENT][NEUTRAL] Sure, hold on one moment.
[CUSTOMER][NEUTRAL] Because right now I only have two options here since.
[AGENT][NEUTRAL] I, I, but I've given you all the answers that I can give you. You can appeal, but we cannot, if a policy only pays out $2000 if you bill me $4000 I can only pay you $2. We've paid you all that we can pay.
[CUSTOMER][NEUTRAL] Uh, I am just confirming the account was submitted. I was just confirming if this was processed out of network. I was also confirming the denial on the claim. You're technically suggesting that you can, we can submit an appeal. I am asking if we can submit an appeal for the out of network or the benefit maximum.
[AGENT][NEGATIVE] It was not.
[AGENT][NEUTRAL] And I've explained that we are a secondary.
[CUSTOMER][NEUTRAL] So technically you're also suggesting that we don't have any appeal rights? We only have two options here for us to appeal.
[AGENT][NEUTRAL] Um, ma'am, I.
[AGENT][NEUTRAL] All I've, all I've explained was that we are a secondary insurance, we don't have in or out of network and in terms of you appealing for the benefit maximum, we have already paid you the benefit maximum. That's all I've explained to you. If you would like to speak to my supervisor, hold on one moment, OK?
[CUSTOMER][NEUTRAL] OK, sure.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEGATIVE] I can't deal with this all around.
[AGENT][NEUTRAL] No I need some water.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] I'm still here.
[AGENT][NEUTRAL] Thank you for holding. I'm just checking on you. I'm waiting for my supervisor, OK?
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Oops, I didn't know I was muted.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Hi, this is [PII].
[AGENT][NEUTRAL] Hey [PII], hold on.
[CUSTOMER][POSITIVE] No worries.
[AGENT][NEUTRAL] Wait, you need the policy number or anything?
[AGENT][NEUTRAL] I already gave it to
[CUSTOMER][NEUTRAL] I think I have the policy number and I am looking for the claim. It ends in 049.
[AGENT][NEUTRAL] Mhm. Well, 084 9.
[CUSTOMER][NEUTRAL] 0849 yes for [PII].
[AGENT][NEUTRAL] Uh, hold on, I have to go back to see the thing, but is it [PII]?
[CUSTOMER][NEUTRAL] Yeah, yeah.
[AGENT][NEUTRAL] OK, you ready?
[AGENT][NEUTRAL] I'm noting it now. OK.
[CUSTOMER][NEUTRAL] Yes, I am. And what's the caller's name?
[AGENT][NEUTRAL] Her name is [PII].
[AGENT][NEUTRAL] Oh, sorry, [PII], sorry, [PII].
[CUSTOMER][POSITIVE] OK perfect thank you.
[CUSTOMER][POSITIVE] [PII]? OK, perfect, um.
[AGENT][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] Let me give me a second to just pull up a note.
[AGENT][NEUTRAL] Alright, hold on one second.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Wait, my note, hold on, I haven't saved it yet.
[CUSTOMER][NEUTRAL] And do you have a call back? No, no.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] No, no, I just, I'm trying to type and the[PII] what's the callback number? Do you have that yet?
[AGENT][NEUTRAL] Mhm. It is [PII].
[CUSTOMER][NEUTRAL] And that was in your um escalation. I'm sorry, I should have just taken it from that.
[AGENT][NEUTRAL] Oh, you're fine.
[CUSTOMER][POSITIVE] OK perfect I am ready thank you thank you.
[AGENT][NEUTRAL] Alright, you're welcome. Hold on one second.
[AGENT][NEUTRAL] Hello [PII].
[CUSTOMER][NEUTRAL] I'm still here.
[AGENT][POSITIVE] Thank you so much for holding. I apologize for that wait. I have [PII] on the line and she'll be assisting you further, OK?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII]. I am the quality assurance.