AccountId: 011433970860
ContactId: 182bde75-d5e4-43af-86f4-f3e303499223
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 707049 ms
Total Talk Time (AGENT): 252847 ms
Total Talk Time (CUSTOMER): 305692 ms
Interruptions: 2
Overall Sentiment: AGENT=0.2, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/12/182bde75-d5e4-43af-86f4-f3e303499223_20250312T15:20_UTC.wav
--------------------------------------------
[CUSTOMER][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Yes, hi, [PII]. Uh, my name is [PII]. Purpose for my call is I file a claim. I received a message that is being processed, but I don't understand. Can you help me with that, please?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Sure, spell your name.
[CUSTOMER][NEUTRAL] [PII] Last name [PII], yeah, [PII]
[AGENT][NEUTRAL] [PII] I just need your first name. [PII]
[CUSTOMER][NEUTRAL] A lot.
[CUSTOMER][NEUTRAL] Yes, [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Thank you, got it. And what is the policy number?
[CUSTOMER][NEUTRAL] 24065887
[AGENT][POSITIVE] And a good phone number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yeah, [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And verify your date of birth, your mailing address and email.
[CUSTOMER][NEUTRAL] Um, [PII]. Email [PII]. Address [PII].
[AGENT][POSITIVE] Alright, thanks for that information.
[AGENT][NEUTRAL] Uh, pronounce your first name for me one more time.
[CUSTOMER][POSITIVE] No problem.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII], OK, I didn't wanna pronounce it incorrectly.
[CUSTOMER][NEUTRAL] That's OK.
[AGENT][NEUTRAL] And so you said that you had a question regarding a claim?
[CUSTOMER][NEUTRAL] Yes, I filed a claim and um it said it processed but I don't, I, I tried to see it online, but for some reason I don't understand what it's saying.
[AGENT][NEUTRAL] OK, is there did it provide you with the claim number or?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Let me check, hold on.
[CUSTOMER][NEUTRAL] Let me see what they gave me um your claim.
[CUSTOMER][NEUTRAL] Um, yes, 357.
[CUSTOMER][NEUTRAL] 3820.
[AGENT][NEUTRAL] OK, I see it.
[AGENT][NEUTRAL] So,
[AGENT][NEUTRAL] One moment.
[AGENT][NEUTRAL] There are 2 remark codes on the claim.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] And I'll read those to you.
[AGENT][NEUTRAL] So for the surgical codes.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It says.
[AGENT][NEUTRAL] The orthodontic benefits are limited to eligible dependent children under the age of [PII]. So ortho is for dependent children under [PII].
[CUSTOMER][NEUTRAL] OK, are done. No, it was the MRI I did.
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] Now that seems different. Hold on a second. Let me look at that code again.
[CUSTOMER][NEUTRAL] OK, let me give you a call. Wait, just one minute. Um 357.
[CUSTOMER][NEUTRAL] 3820.
[AGENT][NEUTRAL] Got it. So for those two, procedure codes, it says that the primary insurance paid those services in full, so there's nothing for us to pay.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then
[CUSTOMER][NEGATIVE] What? Sorry? No, no, they didn't pay me. I paid it.
[CUSTOMER][NEUTRAL] How can they say that?
[AGENT][NEUTRAL] OK. But have you received a copy of the have you received a copy of your
[CUSTOMER][NEUTRAL] I send
[CUSTOMER][NEUTRAL] I sent it.
[AGENT][NEUTRAL] Have you received a copy?
[CUSTOMER][NEUTRAL] I sent it but one.
[CUSTOMER][NEUTRAL] Oh sorry, go ahead.
[AGENT][NEUTRAL] Have you received a copy of the major medical explanation of benefits you sent that in with your claim, right?
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] I said not any of my claims, but what happened I paid it when I went there, so that's why maybe it's showing like a zero balance, but I paid that and you can see that in the explanation that this is how much it costs and.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so if you paid out of pocket prior to the service, later your claim was processed.
[CUSTOMER][NEUTRAL] You know,
[CUSTOMER][NEUTRAL] Not prior.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEGATIVE] I paid it the day I paid it the day I got service before I left the facility, I had to pay it.
[AGENT][NEUTRAL] OK, so if you paid out of pocket, whether it was before or after you had the surgery and then your claim was later processed by your primary, if they paid it in full, then the then the provider will owe you a, a refund. So you have to be overpaid if they paid it in full and you paid it.
[CUSTOMER][NEGATIVE] No, no, no, they didn't, they did not pay it in full. Please look at the um submission that I sent. They paid it less $300 and something dollars. I paid that balance that's why it's showing a 00 balance.
[AGENT][NEGATIVE] No, that's not how it works. They have no idea that you paid out of pocket. The primary wouldn't know that.
[CUSTOMER][NEUTRAL] Oh my God.
[CUSTOMER][MIXED] OK, but no, well,
[CUSTOMER][NEGATIVE] I don't understand this because
[CUSTOMER][NEUTRAL] How do I show proof that I paid it? Like, could I send my credit card or something?
[AGENT][NEUTRAL] OK. Give me just a second, OK?
[CUSTOMER][POSITIVE] Please, thank you.
[CUSTOMER][NEUTRAL] Oh my God.
[CUSTOMER][NEUTRAL] Oh, I have it here.
[CUSTOMER][NEUTRAL] Where is it? Where is it?
[CUSTOMER][NEUTRAL] All right, OK.
[CUSTOMER][POSITIVE] Oh my gosh.
[AGENT][NEUTRAL] OK, so I'm looking at the explanation of benefits from Newport Multi Specialty Surgery.
[AGENT][NEUTRAL] And on the claim that you submitted I'm showing a procedure code.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Of 453-85 and so I'm looking at the primary ELB 45385 they billed for $7,646.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh, is that the right one?
[AGENT][NEUTRAL] And I'm showing
[CUSTOMER][NEGATIVE] It was a MRI.
[AGENT][NEUTRAL] There's other codes. I'm just going, I'm just going code by code.
[CUSTOMER][NEUTRAL] Wait, wait, wait. This is a
[CUSTOMER][NEUTRAL] OK, OK.
[AGENT][NEUTRAL] So now I'm dealing with code 453-85.
[AGENT][NEUTRAL] And if you have a copy of your primary EOB, you may want to follow along to get a better understanding.
[AGENT][NEUTRAL] So for the code 45385, the bill amount was $7,646.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] I don't think that's the one I'm talking about because that's not the one I submitted. I submit the one for, I think, 1300.
[AGENT][NEUTRAL] It is. I'm looking at it.
[AGENT][NEUTRAL] We see a claim for procedure [PII] and 70051.
[CUSTOMER][NEUTRAL] Is it the right
[CUSTOMER][NEUTRAL] You know what I don't?
[CUSTOMER][NEUTRAL] Can I log in, um, if you don't mind, um, what's that? OK, I think [PII]. Is that your site?
[AGENT][NEUTRAL] It is, but I'm looking at the documentation that you sent us from your primary.
[CUSTOMER][NEGATIVE] Mm, I don't think that's the right documentation because it was 1000 something. I think something is wrong. 1 minute.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I'm trying to log in so I'll see what I uploaded.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK, so this one is um for the
[CUSTOMER][NEUTRAL] What date they received on [PII]. Is that the one we're looking at?
[AGENT][NEUTRAL] It's the only one that you submitted, so you should only have one claim.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Right, OK. Let me go to the, I got it. So here, here it goes.
[CUSTOMER][NEUTRAL] Did you see wave imaging, saddleback?
[CUSTOMER][NEUTRAL] That's the one I'm talking about.
[AGENT][NEUTRAL] From whom?
[CUSTOMER][NEUTRAL] Wave W A V E imaging I M A G I
[AGENT][NEUTRAL] And what page is it on? What page is it on?
[CUSTOMER][NEUTRAL] What page is, hold on, so I did the application 123 page 44.
[AGENT][NEUTRAL] OK, for 12:51.
[CUSTOMER][NEUTRAL] 3 and 4.
[CUSTOMER][NEUTRAL] Yeah, just one, let me go back to it. Yes, yes, that's it. I mean, yeah, I'm on bill 1261.
[AGENT][NEUTRAL] Is to build them out?
[CUSTOMER][NEUTRAL] So you see here the amount bill was 1251 plan discounts 943. Your share is 30762.
[CUSTOMER][NEGATIVE] They didn't pay anything. That's what I had to pay 30762.
[CUSTOMER][NEUTRAL] As you see here, wave imaging receipt at the bottom 30762. So I don't know where.
[CUSTOMER][NEUTRAL] That the other info you're talking about coming from because I had, I didn't file something like that.
[AGENT][NEUTRAL] Alright, so let me respond to that. I hadn't gotten to that remark code for that procedure code.
[AGENT][NEUTRAL] And so one moment.
[AGENT][NEUTRAL] So for that procedure code we're requesting a copy of the itemized bill. You only sent the primary ELB so now we need the prime the itemized bill to match this charge for 1251.
[CUSTOMER][NEUTRAL] OK, so how, where do I get the itemized bill from?
[AGENT][NEUTRAL] Where did you have the service done?
[CUSTOMER][NEUTRAL] Um, at wave wave imaging.
[AGENT][NEUTRAL] And that's where you would request the itemized bill.
[CUSTOMER][NEUTRAL] All my bill.
[AGENT][NEUTRAL] From wave imaging.
[CUSTOMER][NEUTRAL] Um, so, sorry, I'm requesting the what?
[AGENT][NEUTRAL] Itemized bill.
[CUSTOMER][NEUTRAL] Itemize, itemize.
[CUSTOMER][NEGATIVE] Oh jeez, Bill. OK, I'll have to go and see them.
[AGENT][NEUTRAL] And so the itemized bill would need to include your total charges, your diagnosis code, which would be the reason that you have the imaging and all procedure codes which we have that on the ELB that's 70551.
[CUSTOMER][NEUTRAL] Diagnosis code. OK. Include total charge, diagnosis code, and what else?
[AGENT][NEUTRAL] Yeah, the, the procedure code will be on there as well. Wage imaging name should be there as well on the form because it's their bill.
[CUSTOMER][NEUTRAL] Procedure.
[CUSTOMER][NEUTRAL] Mm, OK.
[AGENT][NEUTRAL] And just upload that online like you did this one.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK. All right. Thank you so much, ma'am. Appreciate it.
[AGENT][POSITIVE] All righty. Anything else I can assist with today, Ms. [PII]?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] No, that, that's all. It's like, gosh, I went to live imaging and this is what they give me, the receipt, so I didn't know any better.
[AGENT][NEUTRAL] Yeah, we do not process from a receipt so right now we just need the itemized bill from that location.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, I appreciate your help. Thank you. Bye-bye.
[AGENT][POSITIVE] You're welcome, ma'am. Thanks for calling APL have a good day. Bye bye.
[CUSTOMER][POSITIVE] Have a good day. Bye bye.