AccountId: 011433970860
ContactId: 1905b56d-25ce-4354-b397-b47dda12e924
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 780859 ms
Total Talk Time (AGENT): 306140 ms
Total Talk Time (CUSTOMER): 187594 ms
Interruptions: 0
Overall Sentiment: AGENT=0.3, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/01/1905b56d-25ce-4354-b397-b47dda12e924_20250401T17:46_UTC.wav
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[CUSTOMER][NEUTRAL] I mean it's like
[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Yes, and I was calling to follow up on a claim please.
[AGENT][NEUTRAL] OK, I can check the claim for you. And may I have your name and a good contact number?
[CUSTOMER][NEUTRAL] My name is [PII]. Number is [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have your policy number?
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] I have uh the subscriber ID. Will that work for you?
[AGENT][NEUTRAL] Um, it depends. That might be a primary.
[CUSTOMER][NEUTRAL] Um, I don't think I have.
[AGENT][NEUTRAL] Does it start with a letter or 01 or 02?
[CUSTOMER][NEUTRAL] Starts with a letter.
[AGENT][NEUTRAL] Yeah, that's your primary.
[AGENT][NEUTRAL] Um, the APL number usually starts with like a 01 or 02.
[AGENT][NEUTRAL] Or were you trying to reach your primary?
[CUSTOMER][NEUTRAL] Uh let me see if
[CUSTOMER][NEUTRAL] Um, no, I'm, I'm actually a provider trying to follow up on this claim. Let me see if I got a copy of the card.
[AGENT][NEUTRAL] Oh, you're a provider, OK.
[CUSTOMER][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][POSITIVE] Policy number I have it right here, yes ma'am.
[AGENT][NEUTRAL] OK, whenever you're ready.
[CUSTOMER][NEUTRAL] 02520934.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] This is [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service for the claim and the total bill?
[CUSTOMER][NEUTRAL] 924, 24 bill for 4800 even.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And can you verify the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] Uh, anesthesia consultants of Augusta.
[AGENT][NEUTRAL] All right, hold on one moment.
[AGENT][NEUTRAL] Alright, so I'm showing we received the claim on [PII].
[AGENT][NEUTRAL] The claim number is 351.
[AGENT][NEUTRAL] 5863.
[AGENT][NEUTRAL] And on [PII], the claim was denied.
[AGENT][NEUTRAL] Because an anesthesia benefits are based on benefits allowable under surgery benefit. Please send the surgery charges for this date so that both benefits can be considered.
[CUSTOMER][NEUTRAL] Mm, OK.
[CUSTOMER][NEUTRAL] So you guys didn't get the surgery bill yet?
[AGENT][NEUTRAL] Yeah, let me double check, um, but let me see.
[AGENT][NEUTRAL] I'm just waiting for the documents to pop here. Hold on one moment.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] OK, that's not it. Hold on one moment.
[AGENT][NEUTRAL] Do you mind if I place you on just a brief hold? I'm just pulling up the documents that we received for the claim.
[CUSTOMER][POSITIVE] Yeah, no problem.
[AGENT][NEUTRAL] All right, hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Mhm OK here we go.
[AGENT][NEUTRAL] Oh yeah, I wouldn't have found it cause it said 102. I'm looking for close to 1010.
[AGENT][NEUTRAL] OK, what's the question?
[AGENT][NEUTRAL] No, this isn't
[AGENT][NEUTRAL] It looks like this is just for anesthesia. I don't see the er, no, this is just anesthesia.
[AGENT][NEGATIVE] Yeah, no, we haven't received it OK.
[AGENT][NEUTRAL] Hello, [PII].
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] All right. Thank you so much for holding. So, no, the um surgery bill has not been received. This is just a one-page bill and it looks like it's just for anesthesia.
[AGENT][NEUTRAL] It only has the one line on it.
[CUSTOMER][NEUTRAL] Yeah, we're, we're, we're separate from the surgery center that would have performed the service. I'm just surprised you haven't gotten their bill yet.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I guess I need to reach out to them and find out what the deal is, so if I get in touch with them and they get a bill over to you guys, what do I need to do on my end to get this claim reprocessed relooked at?
[AGENT][NEUTRAL] I mean, I would just either them or you just, it needs to just be filed together. I mean, I don't know how that would be. You guys are two different entities.
[CUSTOMER][NEUTRAL] We are, we're a blind provider to that facility, so we just provide the anesthesia for them, but um there, that's different that's the surgery center that's gonna bill you for the actual surgery service.
[AGENT][NEUTRAL] But the surgeries, but would the surgery center still be able to provide you with an itemized bill?
[CUSTOMER][NEUTRAL] Um, I don't know that they'll provide it to me, but they would have billed you guys already. That's why I said it's interesting if you don't have that on file already because their bill's gonna go right out the same time ours was or maybe even a little bit before.
[AGENT][NEUTRAL] Or
[AGENT][NEUTRAL] Well, I was looking for um
[AGENT][NEUTRAL] The billing on the documents received from you all. If you're asking about and I'll have to see if.
[CUSTOMER][NEUTRAL] So like for us, I can, I can send you the medical records that we have um for the anesthesia performed um but we wouldn't have anything else as far as the surgery goes, just the actual, you know, the medical records of what was done and why it was done.
[AGENT][NEUTRAL] OK, so yeah, there is a facility charge here. So they have bills, um,
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me hold on one second, let me see what this is for first thing.
[AGENT][NEUTRAL] OK, yeah.
[AGENT][NEUTRAL] So there I just want to make sure. So yeah, there are some facility charges here, so they have sent in the billing. Um, the only thing that I can do is reach out to claims and see.
[AGENT][NEUTRAL] Because it's two different entities, how that would be handled for the claim, because we're gonna need.
[CUSTOMER][NEUTRAL] Yeah, if you could do that because with these I haven't done much with APL but we are a blind provider so if they paid the other claims they should pay ours too because obviously the patient doesn't get to pick their anesthesia we just provide it for them.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Alright, hold on, um, one moment before I do that, was there anything else I can assist you with today?
[CUSTOMER][POSITIVE] No, I appreciate your help.
[AGENT][POSITIVE] You're very welcome. Well, thanks for calling APL um hold on one moment while I get a representative for you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][NEUTRAL] For calling APL, this is [PII]. How can I help you?
[AGENT][NEUTRAL] Hi, [PII], this is [PII] on the care team. How are you doing?
[CUSTOMER][NEUTRAL] Fine, how are you?
[AGENT][NEUTRAL] I'm doing good. I have a provider on the other line. They, um, well, let me give you the policy number. It's 252.
[AGENT][NEUTRAL] 0934.
[CUSTOMER][NEUTRAL] For [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And it's um claim number 3515863.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] For the data service of [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So we're asking for the surgery bill because they just provided anesthesia um charges. The providers wanted to speak to you because he's saying, well, we're not, we're two separate entities, like we just provide the anesthesia for the hospital because I was telling him that, you know, like for the itemized bill, but he's saying I can't get that because we're not.
[AGENT][NEUTRAL] We just provide the anesthesia and he wants to know, uh,
[AGENT][NEUTRAL] What else he can provide or what he can do, because they, I said, well, they won't provide you with the billing and he was like, well, no, because we would be the third party then.
[AGENT][NEUTRAL] Um, but it looks like the hospital is gonna get denied anyway or has already been denied because they weren't confined long enough, but I didn't tell him that.
[CUSTOMER][NEUTRAL] Mm let me look at this here.
[CUSTOMER][NEUTRAL] Yeah, with this coverage, yeah, surgery benefits are not paid until we have the surgeon's bill. As far as that, this claim wouldn't even be reprocessed until we receive, receive it when, once the surgeon actually filed their claim.
[CUSTOMER][NEUTRAL] So I can let them know that, cause yeah, moving forward, there's nothing else that we would do with their claim until we receive the surgeon's bill.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So, so if this was
[AGENT][NEUTRAL] You know how sometimes, well, never mind, because there, I understand what you're saying. I just
[AGENT][NEUTRAL] Just for me, if this, if this was
[CUSTOMER][NEUTRAL] Yeah, cause they wouldn't, they wouldn't have the surgeons.
[CUSTOMER][NEUTRAL] I'm sorry, go ahead.
[AGENT][NEUTRAL] If this had the like the surgery bill on it and the anesthesia was included, like if this was the anesthesia at the facility, then we would have been able to process everything, right?
[CUSTOMER][NEUTRAL] Yes. But since this is just the anesthesiologist's bill, we're just pretty much letting him know that benefits wouldn't be payable.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Because we need to know what the charges are for.
[CUSTOMER][NEUTRAL] Until we have the surgeon charges. Yeah. Cause the anesthesia is based on a percentage and we can't determine the percentage until we have that surgeon's bill.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Cos.
[AGENT][POSITIVE] OK, I just want to make sure I understood for me so I know what I'm saying. Thank you.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] All right, hold on one moment, OK?
[CUSTOMER][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] What's his name?
[AGENT][NEUTRAL] This is [PII]
[CUSTOMER][NEUTRAL] You said [PII]
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Oh, OK, OK.
[AGENT][NEUTRAL] And did you need the callback number or anything? Are you OK?
[CUSTOMER][NEUTRAL] You can give me the callback number.
[AGENT][NEUTRAL] OK, [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, hold on one second.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Thank you so much for holding. I have [PII] on the line and she'll be assisting you further, OK?
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Hi, [PII], this is [PII]. You have questions in regards.