AccountId: 011433970860
ContactId: 090b87d0-1104-48a2-ab52-b52ac378cfb9
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 437500 ms
Total Talk Time (AGENT): 194184 ms
Total Talk Time (CUSTOMER): 136834 ms
Interruptions: 1
Overall Sentiment: AGENT=1.1, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/11/090b87d0-1104-48a2-ab52-b52ac378cfb9_20250611T14:04_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey, you're breaking up just a little bit. You said your name was?
[AGENT][NEUTRAL] Uh [PII]
[CUSTOMER][NEUTRAL] OK, [PII]. Hi [PII], this is [PII]. I'm calling to check on a claim.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, yeah, I can check on the claim for you. Um, [PII], can I get a good call back number from you first in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you and then do you have that policy number?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] It's 02337055.
[AGENT][NEUTRAL] OK and then what was the name and date of birth for the member please?
[CUSTOMER][NEUTRAL] [PII] [PII]
[AGENT][NEUTRAL] Perfect thank you for verifying that and what was the date of service for for this claim?
[CUSTOMER][NEUTRAL] If I have the claim number, would that be more?
[AGENT][POSITIVE] Oh yeah that'd be great.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 356552-2
[AGENT][POSITIVE] OK thank you give me one moment.
[AGENT][NEUTRAL] OK, so for this claim, [PII], it looks like we're just missing a copy of the primary EOB as this is a secondary medical policy, we do have to have a detailed, uh, EOB from the primary insurance, uh, showing what they contributed to co-pay, deductible or co-insurance.
[CUSTOMER][NEUTRAL] So we faxed this ELB over 3 times.
[AGENT][POSITIVE] Oh goodness.
[CUSTOMER][NEUTRAL] Um, yeah, the first one was faxed in November. The second was in, um, February, and then I faxed it again in, um, April.
[AGENT][NEUTRAL] Um, let's see.
[CUSTOMER][NEUTRAL] 2 [PII]
[AGENT][POSITIVE] That is correct, OK, um.
[AGENT][NEUTRAL] Give me just a moment, let me take a look.
[AGENT][NEUTRAL] Oh, so you said the first time you sent it was in November?
[CUSTOMER][NEUTRAL] Mhm, the first time.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] That one is stating it's a duplicate um.
[AGENT][NEUTRAL] And usually when it does that is again it does have to show I know that there are several different.
[AGENT][NEUTRAL] EOBs um from the primary, but it does have to be detailed showing those amounts paid towards co-pay, deductible and co-insurance. Do you know if that is what's sent to us or what was sent to us?
[CUSTOMER][POSITIVE] Give me one second, yeah, all of these are very detailed.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Hold on one second.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh, I see.
[CUSTOMER][NEUTRAL] Yeah, I mean the plan.
[CUSTOMER][NEUTRAL] What we said it, it has payments the payment amounts, remit code, I mean the service line details, I mean everything.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] That I would think that you guys would need. I'm not.
[CUSTOMER][NEUTRAL] I mean we just literally print the uh the copy of the remit page.
[CUSTOMER][NEUTRAL] And back it
[AGENT][NEUTRAL] OK, so I did see the original claim that we received that simply.
[CUSTOMER][NEUTRAL] And it
[AGENT][NEUTRAL] Said please provide um primary EOB um the second one that we received registered as a duplicate this last one that you sent um that you gave me that claim number for it does state that benefits are only payable if major medical.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] Insurance provider provides benefits if the claim is later paid by major medical insurance, send the explanation of benefits showing benefits were paid. So it again this does not seem like what we got was sufficient.
[CUSTOMER][NEGATIVE] OK, I'll just send it again. So if they didn't pay then you guys are not gonna pay.
[AGENT][NEUTRAL] That is correct. This policy only works if, uh, their primary contributes either to um copay, deductible or co-insurance.
[CUSTOMER][NEUTRAL] So that may be, that may be the.
[AGENT][NEUTRAL] Oh, I see.
[CUSTOMER][NEUTRAL] That may be the, I mean, I was gonna say, do you, can you see what the remit that I said because they didn't pay anything so we just went over that.
[AGENT][NEUTRAL] Oh, I see. Yes, OK, so that's going to be the hiccup then, um, so yes, this, this policy is very dependent on, uh, the primary. So if they don't pay anything this policy can't, this policy is designed to help with uh co-pay deductible co-insurance after they pay.
[CUSTOMER][NEUTRAL] So that could be
[CUSTOMER][NEUTRAL] OK, so, uh, can this claim be sent, I guess, to finish processes so that we can have an EOB?
[CUSTOMER][NEUTRAL] To go ahead and get this account um resolved.
[AGENT][NEUTRAL] Sure, did you just want me to send you a copy of this EOV?
[CUSTOMER][NEUTRAL] Is it gonna say that.
[CUSTOMER][NEUTRAL] I mean,
[CUSTOMER][NEUTRAL] Because if he's gonna just say that you guys need another copy of the EOB then that wouldn't be really.
[AGENT][NEUTRAL] It will state, no ma'am, this particular one does state I think this will the top sentence here uh benefits are payable only if your major medical insurance provider provides benefits um is the first sentence on here so I think that's kind of what you're looking for, correct?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, uh, yes, and, um, the patient, does the patient have does does the patient have a responsibility?
[AGENT][NEUTRAL] So we do not say what is patient responsibility that would be up to the provider.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then did you want me, do you have a fax number, [PII]?
[CUSTOMER][NEUTRAL] Yes, or can you email or no?
[AGENT][NEUTRAL] Um, I don't believe I can at the moment.
[AGENT][NEUTRAL] Is your fax not working?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] I mean it's just easier but you can fax it just um attention it to my name.
[AGENT][NEUTRAL] Oh, sure. OK.
[AGENT][NEUTRAL] Yeah, I can.
[CUSTOMER][NEUTRAL] And then the fax number is [PII].
[AGENT][NEUTRAL] OK, I'm gonna read that back, make sure I heard that correctly. That was [PII].
[CUSTOMER][POSITIVE] Correct mhm.
[AGENT][NEUTRAL] OK, I'll go ahead and get this sent.
[CUSTOMER][NEUTRAL] And then my name is [PII].
[AGENT][NEUTRAL] Oh, that was [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] Got it. OK, I'll go ahead and send that now. I should get it within about 10 minutes or so. Um, was there anything else I could help you with?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] No, that's it.
[AGENT][POSITIVE] Alright, well thanks for giving us a call, [PII]. I hope you have a great rest of your day.
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][POSITIVE] Thank you