AccountId: 011433970860
ContactId: 0c283b1b-2b41-4d8f-ab6a-13cf1590f21b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1034170 ms
Total Talk Time (AGENT): 365578 ms
Total Talk Time (CUSTOMER): 460438 ms
Interruptions: 0
Overall Sentiment: AGENT=0.2, CUSTOMER=1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/16/0c283b1b-2b41-4d8f-ab6a-13cf1590f21b_20250416T14:27_UTC.wav
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[AGENT][NEUTRAL] For calling American Public Life, this is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, good morning. I am trying to make sense of an explanation of benefits that was received for services rendered this year. I'm trying to see if I can find a claim number to give you, but I don't see, let's see, on the EO oh there it is. OK, 357-062-1.
[AGENT][NEUTRAL] And may I have your first name and a good callback number?
[CUSTOMER][NEUTRAL] My first name is [PII] and my call back is [PII].
[AGENT][POSITIVE] Thank you one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Can you verify your date of birth, your mailing address, and your email please, [PII]?
[CUSTOMER][NEUTRAL] [PII]. What was the third?
[AGENT][NEUTRAL] Your email address?
[CUSTOMER][NEUTRAL] They
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you for verifying that information. Please be advised that verification of coverage does not guarantee the payment of a claim, and I have this claim pulled up. And how can I help you today?
[CUSTOMER][NEUTRAL] So I am, I believe I faxed on 3 separate occasions additional information that was requested because when I, when I looked at the reasons for.
[CUSTOMER][NEUTRAL] Non-payment, um, uh, uh, this was not an office visit. this was [PII].
[CUSTOMER][NEUTRAL] Trying to think. He had some pros oh right. He had, um, right, he had an adrenal gland surgery and um spent the night in the hospital. So, um, I submitted the Boca Raton Regional Hospital itemized bill as requested. I submitted the.
[CUSTOMER][NEUTRAL] Um, explanation of benefits from, uh, United Healthcare, um, that, that index showed, let me see.
[CUSTOMER][NEUTRAL] Uh, an anesthesia bill that was, um, being paid or our responsibility.
[CUSTOMER][NEUTRAL] Um, let me just see if there was anything else that we faxed.
[CUSTOMER][NEUTRAL] Oh, and I think on that date as well there was a uh room and board charge that was not covered by the um insurance as well.
[CUSTOMER][NEUTRAL] So those um I'm trying, I'm trying to make sense of the explanation it's asking for um an EOB from the primary which I sent.
[CUSTOMER][NEUTRAL] Uh, the diagnosis, which would have, I'm sure was on either the itemized bill or the HIPAA that I sent.
[CUSTOMER][NEUTRAL] So what is missing to be considered?
[AGENT][NEUTRAL] OK, so I'm reviewing this claim. It looks like they asked for.
[AGENT][NEUTRAL] Itemized bill, diagnosis code.
[AGENT][NEUTRAL] And major medical you'll be on the hospital. Looks like they asked for diagnosis code for data service 124. Looks like it was an inpatient stay.
[AGENT][NEGATIVE] And then looks like the office visit on 123, they denied it's not covered per policy.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] OK. So, I do see the EOB for the anesthesia. It looks like the primary paid in full for the anesthesia on 124 of 25.
[AGENT][NEUTRAL] So there was no copays, co-insurance, or deductibles on that one. So the anesthesia process.
[AGENT][NEGATIVE] And denied if.
[AGENT][NEUTRAL] Paid in full. OK, so let's see.
[CUSTOMER][NEUTRAL] One more question, I'm looking at an EOB from United Healthcare that had the anesthesia listed and also had the surgery listed with an amount due of 27292.
[AGENT][NEUTRAL] OK, let's see if I have that one.
[AGENT][NEUTRAL] OK, so I do see that one data service 124 to provide a bill 321.
[AGENT][NEUTRAL] And let's see what they did with that 11 moment.
[AGENT][NEUTRAL] OK, I don't show that one.
[AGENT][NEUTRAL] So I'll write that one up and send it back for review.
[AGENT][NEUTRAL] And let's see.
[AGENT][NEUTRAL] The office visit on [PII]. The surgery is on 124.
[CUSTOMER][NEUTRAL] Right
[AGENT][NEUTRAL] So the surgery for 124, they're asking for 1500 for the deductible and.
[AGENT][NEUTRAL] They asked for a diagnosis code. So let me go through these claims and see if there's a diagnosis code on here.
[CUSTOMER][NEUTRAL] Do you see a copy of the HIA form that I sent?
[AGENT][NEUTRAL] OK, let me go back. The one that I'm looking at right now is 9 pages.
[AGENT][NEUTRAL] Let me go back through your most recent ones and pull those up.
[CUSTOMER][NEUTRAL] Cause I asked specifically um for some doctors from the hospital that would have all the things that were required by you and I'm looking at the HIPA form and I'm pretty sure it does have a diagnosis code on it for the [PII] surgery.
[AGENT][NEUTRAL] OK, let's see.
[CUSTOMER][NEUTRAL] God, these forms, they're so the print is so small, but they type in the info.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] And that's why we have to carefully review each item submitted.
[AGENT][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] Of course, understood.
[AGENT][NEUTRAL] And we go to the next one I'm sorry, I'm just going through each one.
[CUSTOMER][POSITIVE] No take your time. I appreciate your help.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEGATIVE] And for some reason the system is extremely slow so bear with me.
[CUSTOMER][NEUTRAL] And we thought that computers were going to be the answer, right?
[AGENT][NEUTRAL] No, ma'am.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] I'm uh in uh I'm in the behavioral health field and uh a lot of people that, um, colleagues of mine have switched to electronic records and I'm an old fashioned one. I do. I have paper charts and I find that to be much more efficient for me.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Yes, and I agree.
[CUSTOMER][MIXED] Takes more time, but that's OK.
[AGENT][NEUTRAL] I totally agree with you on that one. Sometimes these computers, they never on time, they never do what you want them to do.
[CUSTOMER][NEUTRAL] Ain't that the truth.
[AGENT][NEUTRAL] OK, I'm seeing the EOB but I'm looking for.
[AGENT][NEUTRAL] The 1500 form with the diagnosis code.
[AGENT][NEUTRAL] And it's 123.
[AGENT][NEUTRAL] Was his hospital.
[AGENT][NEUTRAL] OK. So it looks like.
[AGENT][NEUTRAL] I do see the UBO4 that was submitted, so what I'll do on this one is I'll go back through and review the claims because the diagnosis code for this 123 to 125 state is here so I'll go back through.
[AGENT][NEUTRAL] And see what we can process and what we cannot process and if I need anything else, would it be OK if I call you back at [PII]?
[CUSTOMER][NEUTRAL] Um, let me give you my cell phone. That's the phone I'm calling you on now is I have a landline, but, um, my cell me all the time, so.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, that same area code [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, so I have [PII]. Once I review all of this, I'll go back in and see what we can and cannot process and if I need anything else, I'll give you a call back and let you know either way.
[CUSTOMER][NEUTRAL] OK, great. Now, can I ask you about another claim?
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Well that put that paperwork to the side with notes and go to the next one.
[CUSTOMER][NEUTRAL] That was for my husband. This one is for me.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, this one is um.
[CUSTOMER][NEUTRAL] Wait, hold on a minute, it says boost.
[CUSTOMER][NEUTRAL] So this may be.
[CUSTOMER][NEUTRAL] Oh, OK, um, I, we, uh, he had another hospital stay that was, um, admission date was [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And I submitted the um
[CUSTOMER][NEUTRAL] The meddling claim form.
[CUSTOMER][NEUTRAL] The Boca Regional Hospital bill.
[CUSTOMER][NEUTRAL] And the explanation of benefits from United Healthcare.
[CUSTOMER][NEUTRAL] With um showing the patient responsibility, um.
[CUSTOMER][NEUTRAL] Don't see a claim number. I'm sure I got an EOB from you guys, but I must have misplaced that. Can you pull it by the um data service?
[AGENT][NEUTRAL] And I am looking through and I'm not showing 5:19.
[AGENT][NEUTRAL] In history.
[CUSTOMER][NEUTRAL] We just
[AGENT][NEUTRAL] So I'll have to go through the information you submitted and see if it's in there possibly we overlooked it.
[AGENT][NEUTRAL] So I'll add that to the list to go and review as well.
[CUSTOMER][POSITIVE] OK, all right, perfect, um.
[AGENT][NEUTRAL] Cause I'm not showing it.
[CUSTOMER][NEUTRAL] Do you show 5:14?
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] 5:14.
[AGENT][NEUTRAL] I do show 5:14 looks like.
[AGENT][NEUTRAL] 76,000 and they asked for the diagnosis code.
[CUSTOMER][NEUTRAL] Boy, they do like to have that um trying to think I thought I submitted everything um what is the, does do you show the um.
[CUSTOMER][NEUTRAL] The EOB from United Healthcare.
[AGENT][NEUTRAL] OK, let's see, let me get that pulled up and see if it's attached.
[AGENT][NEUTRAL] So this one looks like it's 4 pages. Let me get it open.
[CUSTOMER][NEUTRAL] Sure
[AGENT][NEUTRAL] This one has admission 519, discharge 522.
[AGENT][NEUTRAL] That one's different.
[AGENT][NEUTRAL] Um.
[AGENT][NEUTRAL] The EOB is 514 to 516, so there is an EOB and on the EOB.
[AGENT][NEUTRAL] There's no co-insurance, no copays, and no deductibles.
[AGENT][NEUTRAL] For Boca Raton Regional.
[AGENT][NEUTRAL] So
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So you, you see the 514, it's basically the inpatient services for 5/14 to 516. He had two back to back admissions for the exact same condition, um, so the, um, the bill diagnosis uh from the hospital should have been covered.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, both, you know, the entirety of it, admit discharge, admit discharge, and the bill that we responsible for was for um.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Just I'm looking, so it's saying it's giving a balance due but it's not saying what date that amount is due for it's just saying what the charge is and what is due to um the hospital and I'm pretty sure I sent this.
[AGENT][NEUTRAL] And what is it saying?
[CUSTOMER][NEUTRAL] So it should look.
[AGENT][NEUTRAL] I'm sorry, what's your balance? What does it say in the balance is for that hospital stay?
[CUSTOMER][NEUTRAL] 800
[AGENT][NEGATIVE] OK, so on this for data service 514 to 516, it does have a plan does not cover and it's not covering $800 on the room and board line.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK, alright, that's what I needed to know, um, I, I wasn't sure if it was something that was covered or not covered, so that's fine, so we don't have to do anything with this claim that's one down.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] But the other, the other one with the deductible and the out of the [PII].
[CUSTOMER][NEUTRAL] Um, that we paid and the 1500 that we paid um to cover the deductible, those two are the things that you're going to look over and um resubmit if eligible, correct?
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][POSITIVE] OK, fabulous.
[CUSTOMER][NEUTRAL] Um, and typically the, the process is how long just so I know when to put it in my tickler to follow up.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Normal turnaround time is anywhere from 7 to 10 business days, but I'll go through this file and then give you a call back today and let you know what we can and cannot allow and if I need anything extra I'll give you a call back on that one as well today.
[CUSTOMER][POSITIVE] Oh, OK. All right, perfect. Appreciate all your help. Thank you so much and um I'll wait to hear.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][POSITIVE] You are so welcome.
[AGENT][NEUTRAL] [PII], is there anything else I can assist you with?
[CUSTOMER][POSITIVE] You have a beautiful
[CUSTOMER][POSITIVE] Not at all, not at all, thank you.
[AGENT][POSITIVE] You're so welcome and thank you for calling American Public Life, [PII]. Have a great day and I'll talk to you soon.
[CUSTOMER][POSITIVE] OK great thanks bye bye.
[AGENT][POSITIVE] You're welcome bye bye.