AccountId: 011433970860
ContactId: 13df913a-3c8f-4281-8696-8dc376c99fa7
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 639450 ms
Total Talk Time (AGENT): 186552 ms
Total Talk Time (CUSTOMER): 103879 ms
Interruptions: 0
Overall Sentiment: AGENT=0.7, CUSTOMER=-0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/20/13df913a-3c8f-4281-8696-8dc376c99fa7_20250620T13:00_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] Hi, [PII]. My name is [PII] and I'm calling from facility uh regarding claim status.
[AGENT][POSITIVE] OK, well, I'll be more than happy to help you with the claim status. And [PII], may I have a good contact number in case we're disconnected and the policy number?
[CUSTOMER][NEUTRAL] Sure. The callback number is [PII].
[CUSTOMER][NEUTRAL] Uh, this is a direct line, no extension.
[AGENT][NEUTRAL] All right, and the member's policy number?
[CUSTOMER][NEUTRAL] 02120179 M as in Mike, L as in Lima, number 7.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Member's name is [PII] name is [PII]. Date of birth [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. [PII], may I have the date of service and the total bill for the claim?
[CUSTOMER][NEUTRAL] That of service was in the range of [PII].
[CUSTOMER][NEUTRAL] Bill amount $316,875.71.
[AGENT][POSITIVE] Alright, thank you for that hold on one moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] It's the same.
[AGENT][NEUTRAL] Alright, do you mind if I place you on just a brief hold while I take a look at the claims?
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] Thank you. And um while I'm doing that, what is the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] The provider is HA Florida West Side Hospital.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Oh.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] 126
[AGENT][NEUTRAL] So duplicate, I think.
[AGENT][NEUTRAL] Oh that's not what that is.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Oh, it's the same thing. OK.
[AGENT][NEUTRAL] Hello, [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Thank you so much for holding. I apologize for that wait. So we received um a claim on the data service about 3 times, so I had to go through them. Um, but for your particular claim, we received the claim on
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] The claim number is 354.
[AGENT][NEUTRAL] 8266
[AGENT][NEUTRAL] And on [PII], the claim was denied, requesting the explanation of benefits from primary insurance.
[CUSTOMER][NEUTRAL] OK. And it was received on [PII], right?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] We need to resubmit this claim with primary U as a corrected claim.
[AGENT][NEUTRAL] Yes, and then we'll continue processing.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] You know what? Hold on one moment.
[CUSTOMER][NEUTRAL] What is?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Was this one
[AGENT][NEUTRAL] It's a different day of service. Hold on one moment, OK?
[AGENT][NEUTRAL] Because the, the, it was resubmitted, but the denial reason on the resubmission is that it
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It's a duplicate, but I don't.
[AGENT][NEUTRAL] And that it's been paid to the insured, but I don't see.
[AGENT][NEUTRAL] I'm trying to see what claim this was paid out on so I can let you know what happened, but I don't see anything from the insured. So can I um place you on a brief hold to look into that?
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, wait a minute now, what?
[AGENT][NEUTRAL] It's just these two.
[AGENT][NEGATIVE] Oh, no, it's not.
[AGENT][NEUTRAL] This is the same thing.
[AGENT][NEUTRAL] I I don't know why I thought it was a different data service.
[AGENT][NEUTRAL] OK, hello, [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] All right, so it looks like the insured submitted the claim and then you all as a provider submitted the claim. Um, so the claim was paid out to the insured.
[AGENT][NEGATIVE] And then when we received your claim, we asked for the explanation of benefits and once we saw that, um, it had been paid out to the insured when you resubmitted with the explanation of benefits, it was denied, um, saying that it has been, it's a duplicate and it's been paid to the insured.
[CUSTOMER][NEUTRAL] To the member?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Just give me a moment.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] And assignment of benefits was not honored due to reason why it was paid to the member.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Uh, why the claim was paid to the member directly?
[AGENT][NEUTRAL] Because the member submitted the claim before your claim that had the assignment of benefits on it.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] So we process the claims as they come in, yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] For the provider.
[CUSTOMER][NEUTRAL] OK, thank you. And what is the paid amount to the patient?
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Uh, we can't give that information because it's the patient's claim, but you can reach out to the patient to see what the outcome was.
[CUSTOMER][NEUTRAL] So we need to get that information from the patient.
[AGENT][NEUTRAL] Yes, I cannot give you the patient's claim status.
[CUSTOMER][NEUTRAL] Thank you. What will be the reference number?
[AGENT][NEUTRAL] So there's no call reference number, but you can use my name and today's date and again that's [PII] initial to my last name is [PII].
[CUSTOMER][POSITIVE] Thank you so much for your assistance. You have a great day ahead.
[AGENT][POSITIVE] Thank you, you also, and thanks for calling APL. Bye-bye.
[CUSTOMER][POSITIVE] Thank you, bye-bye.