AccountId: 011433970860
ContactId: 0bb37baa-2e49-4f0d-96d2-567bb9924112
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 790979 ms
Total Talk Time (AGENT): 467520 ms
Total Talk Time (CUSTOMER): 265724 ms
Interruptions: 3
Overall Sentiment: AGENT=0.6, CUSTOMER=0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/04/0bb37baa-2e49-4f0d-96d2-567bb9924112_20250604T20:05_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How can I help you?
[CUSTOMER][POSITIVE] Hey [PII], uh, I have an insured that needs some, uh, some assistance. She's already set up on the online service center, so I did that one, yay, got her set up on there.
[AGENT][POSITIVE] OK, good
[CUSTOMER][NEUTRAL] She's calling about a claim she had received a text saying that her claim has been processed, and I explained to her on that claim it's showing for a data service of 422.
[CUSTOMER][NEGATIVE] And the claim was processed as needing additional information on the billing, it does have the diagnosis code, but she is saying that's not the correct date of service. It was supposed to be for 418. On the billing, it does show a data service for 418 along with the a different date, but she just wanted her anesthesia paid. She doesn't want anything else, she just want anesthesia.
[CUSTOMER][NEGATIVE] And she's scared that she's sending uh her complete EOB for that time span that we're gonna be paying for something that we shouldn't be.
[AGENT][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] And so she wants to know specifically what we would need.
[CUSTOMER][NEUTRAL] To see, but, and I also wanted, if you can look at this with me, I give you that policy number. I'm sorry, I'm just yampering.
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] It's uh policy number 2054422.
[AGENT][NEUTRAL] 2, you cut out a little bit 2054.
[CUSTOMER][NEUTRAL] 422.
[AGENT][NEUTRAL] 205422 and I missing the number?
[CUSTOMER][NEUTRAL] 20544222422.
[AGENT][NEUTRAL] 4422 got it got it [PII].
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] And that most, yeah, and that most recent claim, that is the one where uh it's asking for additional information like the EOB or the diagnosis code. But the diagnosis code is on the claim and I did highlight it. But um if you look at that.
[CUSTOMER][NEUTRAL] Oh Lord, [PII].
[CUSTOMER][NEUTRAL] That first line it shows 422 and then it shows 418.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] She is saying that she didn't have surgery on [PII]. She had it on [PII]. She has billing for her anesthesia. It's under claim number 3606196, where we're needing diagnosis code.
[AGENT][NEUTRAL] OK, I'm looking at that first claim.
[AGENT][NEUTRAL] Just bear with me for a moment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I'm sorry.
[AGENT][NEUTRAL] That's OK, that's 8968. I'm looking at that one first.
[AGENT][NEUTRAL] OK, I do see the diagnosis code. It does say 422.
[AGENT][NEUTRAL] And it looks like an arthroscopic surgery.
[AGENT][NEGATIVE] And you're saying she said she doesn't want us to acknowledge that? well then why did you send it in.
[CUSTOMER][NEUTRAL] She, she said the date is for [PII], which I do show on that first line.
[CUSTOMER][NEUTRAL] Well, 3rd, I guess, maybe. I
[AGENT][NEUTRAL] Yeah, the claim date is 4/22. It should have been 4-18. That's, she's right. I believe that's the way I read it because I see 418 charge, see, I see it right there next to the CPT and modifier. So it looks like it should have been 418.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] OK, should have been.
[CUSTOMER][NEUTRAL] And then the one that she's more concerned about is for the other date or the other claim number, which is for anesthesia, which is 4:18, but uh we're needing diagnosis codes, which we have for that one.
[CUSTOMER][POSITIVE] Oh, so happy when people get their stuff straightened out.
[AGENT][NEUTRAL] OK, and that one's to [PII], so.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Do do do do do do.
[AGENT][NEUTRAL] I'm gonna pull up that
[CUSTOMER][NEUTRAL] Do do do do do.
[AGENT][NEUTRAL] Paperwork.
[CUSTOMER][NEUTRAL] Do do do do
[CUSTOMER][NEUTRAL] I need a nap.
[CUSTOMER][NEUTRAL] I would say I need a drink, but I don't need that. I need a nap.
[CUSTOMER][NEUTRAL] No coffee, just a nap.
[AGENT][NEUTRAL] OK, I'm pulling up that mail right now.
[CUSTOMER][POSITIVE] OK, you rock.
[AGENT][NEUTRAL] OK. [PII] and anesthesia.
[AGENT][NEGATIVE] That's her looks like her EOB. It's really hard to read it.
[AGENT][NEUTRAL] Uh, 4:18 anesthesia service, that's the bill.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so we have the diagnosis code under that other male number for this procedure and whoever entered that one entered the data service at 422 and it should have been 418, right?
[AGENT][POSITIVE] I got it right.
[CUSTOMER][POSITIVE] Yes, ma'am, yes.
[AGENT][NEUTRAL] And that's both for [PII]. OK, so what I'm gonna do is, um, you can, I guess transfer her over and her name is [PII]. She's everything's been verified.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Yes, I verify all her information and I've also helped her with setting up on the online service center.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Which she is on there.
[AGENT][NEUTRAL] And
[CUSTOMER][NEUTRAL] Oh,
[AGENT][NEUTRAL] Is her call back that number listed there, the 678-382 number or no?
[CUSTOMER][NEUTRAL] Uh yes.
[CUSTOMER][NEUTRAL] See, that is her number.
[AGENT][NEUTRAL] [PII]. OK, alright, so you can go ahead and transfer her over and I'm sorry you did say everything was verified, right? You said that.
[CUSTOMER][NEUTRAL] I did, yes ma'am.
[AGENT][NEUTRAL] Sorry, it's, it's been a long Monday again and it's Wednesday, so yeah.
[CUSTOMER][POSITIVE] Girl, it's been a long week, especially with this OSC. I'm so happy when people get their stuff together.
[AGENT][NEUTRAL] It.
[AGENT][NEUTRAL] I hear you.
[CUSTOMER][NEUTRAL] Try not to lose it.
[AGENT][NEUTRAL] I hear you.
[CUSTOMER][NEGATIVE] You know it's bad when you're, you'd rather get a provider script reader call for benefits and have to do with OSC people calling. I'm just saying.
[AGENT][NEUTRAL] I, I, I, I get it. I feel the same way.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So you may transfer her by there and I will take it from here.
[CUSTOMER][POSITIVE] Wow.
[CUSTOMER][POSITIVE] You rock, as always. Thank you, Ms. [PII].
[AGENT][POSITIVE] No problem.
[CUSTOMER][POSITIVE] Have a, have a great one.
[AGENT][POSITIVE] You too thanks.
[CUSTOMER][NEUTRAL] Bye.
[AGENT][NEUTRAL] Bye.
[AGENT][NEUTRAL] Hello Ms. [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Hi, my name is [PII]. I'm on the claim support team, um, so I was looking over your paperwork and, um, I, I.
[AGENT][NEUTRAL] I understand that um it looks like we uh acknowledged an incorrect date there was a posting date on that surgical claim. Um it should have been [PII] to match that anesthesia claim that was on [PII]. Do I have that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK. And then um we're just wanting to, you're just wanting us to acknowledge the anesthesia, uh benefits that are under that 4 I'm sorry, that 418 day, correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, and not the surgery itself.
[CUSTOMER][NEUTRAL] And, and here,
[CUSTOMER][POSITIVE] Well, no, because I, no, no, not the surgery, just the anesthesia portion because all of that, my primary took care of that and I paid what was due on my part, so that has been taken care of.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And you don't want, you don't want us to uh look at that sur surgical uh uh charge at all. You just want us to acknowledge that, uh, anesthesia claim for [PII]. And then I think we asked for a diagnosis code.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yes, I have a separate EOB for that.
[AGENT][NEUTRAL] OK. And then I see that we asked for a diagnosis code, however, you did submit that when you submitted it for the surgical service that was done on that same day. So what I'm gonna do is I'm going to reach out to the adjuster that processed your claim, and I'm gonna point her attention to the fact that the data service should have been the 418.
[AGENT][NEUTRAL] And um we're what might happen with that is that that might have to be corrected I would think just for our records because any time you send anything and we do have to acknowledge that uh service so if there's something that's missing that's needed uh we uh reach out and request that information from you but it does need.
[AGENT][NEUTRAL] Match what was sent in so like I said we do have to acknowledge it now because um we did ask for additional information for that uh like I said I'm just gonna let the adjuster know that we we just need to correct the date on that and nothing will be processed until we receive the information that was requested so as long as you don't send that.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] With me
[AGENT][NEUTRAL] Information in um.
[CUSTOMER][NEUTRAL] What
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] Cause it looks like on that one they were requesting the explanation of benefits for the surgery, although um that wasn't, we just have the um actual itemized statement itself from the orthopedic office. So as long as you don't send that information in for that explanation of benefits, then we won't reprocess it. But like I said, I am gonna have them correct the date cause the date of service needs to be corrected.
[CUSTOMER][NEUTRAL] OK, was it um was it incorrect on what I submitted or?
[AGENT][NEUTRAL] No, no, it's, I think it was just kind of an oversight because on the itemized statement they ran the numbers together and you have to look at that next line so uh it's like a.
[CUSTOMER][NEUTRAL] Was it an oversize.
[AGENT][NEUTRAL] Um, there are series of numbers that the provider used when they um when they created this itemized statement, so they included the batch date and what that usually means is that's their bill date. So if you look under the first procedure for your on the very bottom it says claim 422-25, that's the actual claim date that the claim was created, but the date of service, it says [PII] and then it has the CHG next.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] To it, that's the charge. So that should have been the date of service. And like I said, I think that was just overlooked and that was uh uh a mistake on our part, um, you know, an oversight. So like I said, I'm gonna have her correct that date, but I'm gonna let her know that we're just needing to uh acknowledge that anesthesia charge and that we have the diagnosis code from that surgery on [PII] so we can uh have that claim reprocessed for the anesthesia.
[CUSTOMER][POSITIVE] Got you.
[CUSTOMER][NEUTRAL] OK, but I also just looking on my insurance website. I have a separate EOB just for that that portion. Would you like for me to upload it here under even though it says process, it has an, um, download document? Would you like for me to upload it there so you all can have that in addition to what you have?
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Well, you sent us the explanation of benefit for the anesthesia charge. So we have, I believe that's what we have. Let's see.
[CUSTOMER][NEUTRAL] OK. OK.
[AGENT][NEUTRAL] Because it shows let's see facility charge 1078.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] And then your portion was applied to your deductible was $400 is that right?
[CUSTOMER][NEUTRAL] Right, right.
[AGENT][NEUTRAL] OK, and then we have the itemized bill that shows those charges um for the anesthesia and then um the amount that was paid and then it shows the deductible on that itemized statement as well as 400.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So, um, like I said, I'm just gonna let her know we have the diagnosis code on file and ask her to reprocess it and then just ask her to go ahead and correct that date for the surgery charge. But at that time, I'll let her know that you're not going to be resubmitting. Um, and like I said, usually it, as long as um you don't resubmit that explanation of benefits that nothing will be processed again for the surgery itself.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then I'll note your file and then I do have a callback number for you of [PII], is that right?
[CUSTOMER][NEUTRAL] Yeah, mhm.
[AGENT][NEUTRAL] OK, just in case I need to uh give you any additional information or need anything else, I'll call you back, but otherwise, um, it's usually if you allow us, uh, a 1 to 3 business days to get this turned around and reprocessed, it usually doesn't take that long but just in case the adjuster's not in or um.
[CUSTOMER][NEUTRAL] That
[AGENT][POSITIVE] Like if she may be gone for today so it might be tomorrow before it's processed, but I'm gonna send her that message and then if anything else is needed I will definitely give you a call back and let you know but it should be, um, I think, I think it's pretty forward here what we're doing and did you have any other questions at this time, Ms. [PII]?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That was it.
[AGENT][POSITIVE] OK, alright, well we'll we'll get this taken care of for you. You're so welcome and thank you for being a valued customer and I hope you have a great day.
[CUSTOMER][POSITIVE] That was it. Thank you very much.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][POSITIVE] You do the same thank you.
[AGENT][POSITIVE] Thank you bye bye.
[CUSTOMER][NEUTRAL] Bye bye.