AccountId: 011433970860
ContactId: 1da6d93d-6ff7-44c0-864b-ab7910d8813c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 798440 ms
Total Talk Time (AGENT): 492866 ms
Total Talk Time (CUSTOMER): 291968 ms
Interruptions: 12
Overall Sentiment: AGENT=-0.2, CUSTOMER=1.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/02/1da6d93d-6ff7-44c0-864b-ab7910d8813c_20250402T16:52_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey, my friend, it's me.
[AGENT][NEUTRAL] Hey, how are you?
[CUSTOMER][POSITIVE] I'm good. How are you doing?
[AGENT][NEUTRAL] Oh, I've already talked to Mr. [PII] today.
[CUSTOMER][NEUTRAL] Again.
[AGENT][NEGATIVE] Girl, he was crying.
[CUSTOMER][NEUTRAL] Isn't it
[CUSTOMER][NEGATIVE] Isn't it the most frustrating thing ever to be able to sit, I mean to have to sit here.
[CUSTOMER][NEGATIVE] And not be able to help because we just need to, oh my God, it just tears me apart.
[AGENT][NEGATIVE] Yeah, yeah, he was crying. He was like, I'm a stone's throw away from losing my house, and I said, Mr. [PII], if I could get it myself, I would. I was on the phone with you when when you were there telling them what we need. All I can do is wait.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] He needs to go back to them and tell them.
[AGENT][NEUTRAL] And he was like,
[AGENT][NEGATIVE] Yeah, he said I'm calling him now. He didn't even say bye he didn't say thank you, he said I'm calling him now and hung up.
[AGENT][NEGATIVE] Which I know that wasn't, you know, anything ugly towards me. He's just, he's stressed out, so.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEGATIVE] He stretched out and he's screaming. Girl, they called the other day and they were both screaming him and some lady, I don't know, they were screaming at each other. I'm like, well, you ain't gonna get better if you can't handle it. Just calm yourself down. Anyway, but I didn't say that. Um, I
[AGENT][NEUTRAL] What?
[AGENT][NEUTRAL] Yeah, [PII], [PII].
[CUSTOMER][POSITIVE] That's right. It's all about the summer, baby.
[AGENT][NEUTRAL] Yeah,
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] I have a provider on the line and I'm just confused because I don't know exactly what to tell him. Can you look at this super quick?
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I've got policy number 1369753.
[CUSTOMER][NEUTRAL] From [PII] or something.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Data service 72924.
[CUSTOMER][NEUTRAL] And it's for the 1692 charge.
[CUSTOMER][NEUTRAL] Greater Florida anesthesiologist.
[AGENT][NEUTRAL] Do you have a claim number?
[CUSTOMER][NEUTRAL] So they submitted, I've got several, the original claim submitted was um.
[AGENT][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] 349-7581 where we are pended that claim for the EOB.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then it looks like.
[CUSTOMER][NEUTRAL] The insured must have sent the EOB on claim number 3513863, and we denied this maximum benefit met for that day.
[CUSTOMER][NEUTRAL] To the insured.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Hm.
[CUSTOMER][NEGATIVE] And then it looks like the insurance sent it again we denied it as a duplicate and then it looks like finally the provider sent something in and denied it as a duplicate.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] So I'm really getting confused with these insured and providers submitted. I mean, if the insured sent it back in, wouldn't we have added that to the professional fee claim? I mean, or instead of denying the duplicate professional fee, wouldn't we have denied it as max met?
[AGENT][NEUTRAL] Uh, let's see.
[CUSTOMER][NEUTRAL] Of course if they just sent the UBO4 again it would just be the duplicate but I mean.
[AGENT][NEUTRAL] Right, OK, so 7581.
[CUSTOMER][NEGATIVE] That, that's, that's confusing me. I just don't know what they're doing.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so we have outpatient mac.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] 1000 per calendar.
[CUSTOMER][NEUTRAL] And he's not gonna get an EOB with the max med.
[AGENT][NEUTRAL] I mean, the provider should.
[AGENT][NEUTRAL] Because it's
[CUSTOMER][NEUTRAL] Well, they're just gonna get that duplicate EOB if I, if I fax an EOB, it's just gonna be a duplicate.
[AGENT][NEUTRAL] Oh, right, right, right, right. OK. Um, so,
[CUSTOMER][NEUTRAL] See what I'm saying?
[CUSTOMER][NEUTRAL] Girl, you know, we know these men that call from, you know, what they're gonna ask.
[AGENT][POSITIVE] Yes, yes, yes.
[CUSTOMER][NEUTRAL] And if I give him a claim number to get off from the OSC it's just gonna be a duplicate claim, but I'm gonna say well we maxed out the benefit for that data service.
[AGENT][NEUTRAL] Rot, so rot. So that doesn't help them at all. OK, so let's see, let's put in.
[CUSTOMER][NEUTRAL] You know,
[CUSTOMER][NEUTRAL] Nor us because if I give him that duplicate claim number then he prints it and then it he calls back because.
[AGENT][NEUTRAL] Right, because he's like, well, what does this mean?
[CUSTOMER][NEUTRAL] It's a duplicate.
[AGENT][NEUTRAL] OK, so we have maxed it that is valid, um, for that date of service so now.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] I just need to figure out what is going on over here, OK.
[CUSTOMER][NEUTRAL] So I mean do I give him the original claim number and just give him the that it was pending for the primary EOB and then he's gonna say well we sent that back in yada yada well that was denied as a duplicate and then I could say, but I will let you know that benefit max for that data service has been met. I could do that. I could go from that angle.
[AGENT][NEUTRAL] Yeah, you could. Let me, wait, so the payment, um, it says facility.
[AGENT][NEUTRAL] And so I'm trying to figure out if this is gonna be the same.
[AGENT][NEUTRAL] Person like the same facility?
[AGENT][NEUTRAL] As what we were asking.
[CUSTOMER][NEUTRAL] Well,
[CUSTOMER][NEUTRAL] It's just the anesthesia.
[AGENT][POSITIVE] Oh, it's the, mm, that's right, that's right. This was the CMS and we paid the facility for the actual surgery is what we did.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, I see, I see, I see.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] So surgery we paid the max for that date for outpatient anesthesiologist sent it in, we did not, so what should have happened is on that very first one, they shouldn't have even denied it is what it looks like to me they should have.
[CUSTOMER][NEUTRAL] 7581.
[AGENT][NEGATIVE] Like they shouldn't have asked for the EOB, they should have just asked for.
[AGENT][NEUTRAL] The
[AGENT][NEUTRAL] Um,
[AGENT][NEGATIVE] Or they should have just denied us max because 7581 that came in on [PII] was processed on [PII] and the one that we processed for payment was already there.
[CUSTOMER][NEUTRAL] Yeah, we would have already paid it out.
[AGENT][NEGATIVE] So they shouldn't have even denied it that way. They should have just said this is next, um.
[AGENT][NEUTRAL] So then,
[CUSTOMER][NEUTRAL] Yeah, so it just said that D20146.
[AGENT][NEUTRAL] Mhm. Now there is a charge, the DM 146, so that's claim 3863.
[CUSTOMER][NEUTRAL] But that's to the insured.
[AGENT][POSITIVE] Is it? Oh, it is, you're right, dang it.
[AGENT][NEUTRAL] Uh, where is that one?
[AGENT][NEUTRAL] And we're sure that that was insured submitted?
[CUSTOMER][NEUTRAL] Yeah, I've got it pulled up. That's the 351-386-3.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, he sent it in on uh OSC.
[AGENT][POSITIVE] Got you.
[AGENT][NEUTRAL] Got you. OK, and then we denied a duplicate to the insured.
[CUSTOMER][NEUTRAL] But why wouldn't we have
[AGENT][NEUTRAL] And then duplicate again.
[CUSTOMER][NEUTRAL] I mean he's just sending in the EOB. I don't know why.
[AGENT][NEUTRAL] Yeah, so.
[CUSTOMER][NEUTRAL] Well, maybe not.
[CUSTOMER][NEUTRAL] No, he's got the bill too.
[AGENT][NEUTRAL] The
[AGENT][NEUTRAL] The last one that 3158, that would have been valid for the provider.
[AGENT][NEGATIVE] Had we denied to the provider as needing like.
[AGENT][NEUTRAL] If we had denied it appropriately, um, as Max, mhm.
[CUSTOMER][NEUTRAL] The 10460146, yeah.
[AGENT][NEUTRAL] So had we already denied that this was maxed then I would say yes that would be valid um but this is technically in my opinion it's not a duplicate because now we have the EOB and previously we did not.
[CUSTOMER][NEUTRAL] I didn't pull up that claim. Did you just see if we did?
[AGENT][NEUTRAL] Yeah, we got the EOB with the 3158 where previously we did not it as needing the EOB so it's technically not a duplicate so what what we can do is we can send.
[CUSTOMER][POSITIVE] Got you.
[CUSTOMER][POSITIVE] Got you.
[AGENT][NEGATIVE] Can send an error.
[AGENT][NEUTRAL] To the examiner and let them know that this is not duplicate that we previously requested an EOB that way they do get an an EOB that says that it's maxed.
[AGENT][NEUTRAL] So the claim can be reprocessed that way they have something physical that says it's maxed so that if they choose, you know, to build the insured they have something to kind of, you know, dot their I's and cross their T's, um, that says, well your insurance didn't pay, you know, but um other than that, you know, because we can't, we can't do like benefit corrections and stuff right now.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So,
[AGENT][NEUTRAL] It shouldn't have never been denied in the first place as needing an EOB because it had already been maxed so I don't know that may be.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEGATIVE] Two errors that I need to send, I don't know, or maybe just the one for the original.
[AGENT][NEUTRAL] And then this one would be valid?
[AGENT][NEUTRAL] I don't know.
[CUSTOMER][NEUTRAL] That's true.
[AGENT][NEUTRAL] Because technically it would be a duplicate even with the EOB because we had already denied it as maxed.
[AGENT][NEUTRAL] So
[CUSTOMER][NEUTRAL] OK, so what I can tell him is I'm gonna.
[AGENT][NEUTRAL] I don't know. I may reach out to [PII] on that one, but.
[CUSTOMER][NEUTRAL] Yeah, I just didn't know what to tell him because
[AGENT][NEUTRAL] Even
[AGENT][NEUTRAL] Yeah, so I would let him know that when we received his claim or that claim and it was denied as needing the EOB, the maximum had already been met.
[CUSTOMER][NEUTRAL] Uh, you know,
[AGENT][NEUTRAL] And
[CUSTOMER][POSITIVE] And we're gonna get it corrected. I got you. I, I'm on board now.
[AGENT][POSITIVE] Mhm we're gonna get it corrected and yeah and what we'll do is um.
[AGENT][NEUTRAL] Yeah, because they didn't even include that right we'll get uh an updated slash corrected EOB to them regarding that particular data service in that claim.
[CUSTOMER][NEUTRAL] To the OB to them, yeah.
[CUSTOMER][POSITIVE] Got you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then that way if they, you know, you're not really having to tell them that there was an error or whatever you can just let them know like yes we did request the EOB however.
[AGENT][NEUTRAL] The maximum had already been met and so, you know.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] We can we're gonna update our information, send you a corrected DOB.
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] And then that way you'll also have that information.
[CUSTOMER][POSITIVE] Got you.
[CUSTOMER][NEUTRAL] OK, so you're gonna, are you gonna send the, um, or you need me to?
[AGENT][POSITIVE] Sound good?
[AGENT][NEUTRAL] Um, I can because I'm going to, um, reach out to [PII] and ask her if she, because it's two different examiners.
[AGENT][NEUTRAL] Ask her if she feels like it's the very first one.
[AGENT][POSITIVE] I feel like it's honestly, I just feel like it's the very first one that needs the air because it shouldn't have ever went out.
[CUSTOMER][POSITIVE] Got you.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] That way.
[CUSTOMER][POSITIVE] Got you.
[AGENT][POSITIVE] So I'll send it. It's no problem at all. Um, I will send that over to them and then they're supposed to get those processed within 24 hours so I would say at least either by end of business today or tomorrow it'll be reprocessed and so you know 7 to 10 business days for them to actually get it.
[CUSTOMER][POSITIVE] Oh, got you. Thank you, thank you.
[CUSTOMER][POSITIVE] Perfect.
[AGENT][NEUTRAL] Yup.
[CUSTOMER][NEUTRAL] I try not to every give a time frame, unless they ask, especially not with the mail.
[AGENT][NEUTRAL] Oh yeah I know I, I tell them like we ask that you allow 7 to 10 business days for processing and then I'll be like and like if they don't have direct deposit or if it's a provider I'll be like and you know after that it's up to the post office and when you get it it could be a week it could be 3 weeks I don't know you know you never know with the post office.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right. Exactly.
[AGENT][NEUTRAL] If you feel like it's been an extended amount of time, call us and let us know we can check the status we can let you know when that was mailed out we can verify address we can do all of that and then you know if you've not received it, you know, we'll, you know, we'll figure that out from there but this is what we, we ask you to do this is what we ask for you to allow us.
[CUSTOMER][POSITIVE] Perfect.
[CUSTOMER][POSITIVE] Perfect.
[CUSTOMER][POSITIVE] Got you, got you.
[AGENT][NEGATIVE] We have no control over the post office, don't hold us accountable for that.
[CUSTOMER][POSITIVE] That's right.
[CUSTOMER][POSITIVE] That's right. OK, well, good, thank you. That was kind of, that was kind of felt like I was.
[AGENT][POSITIVE] Oh goodness. But yeah.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEGATIVE] Running around the tree, couldn't get up the tree on that one.
[AGENT][NEGATIVE] Yeah, yeah, well, like I said it wouldn't have been the mess that it is had they not requested the EOB in the first place, yep, so that's why I'm just kind of like I don't even want to send that second error because technically it shouldn't have ever went out requesting this in the first place.
[CUSTOMER][NEUTRAL] If it was processed, yeah.
[CUSTOMER][NEUTRAL] Yup.
[AGENT][NEGATIVE] So that's really where the, the dominoes started falling from there.
[CUSTOMER][POSITIVE] Got you. All right.
[CUSTOMER][NEUTRAL] Well, I will get back with Mr. [PII] and let him know.
[AGENT][NEUTRAL] All right.
[CUSTOMER][POSITIVE] And I appreciate you.
[AGENT][POSITIVE] No problem at all ma'am.
[CUSTOMER][POSITIVE] All right. Thank you, [PII]. Take care. Bye-bye.
[AGENT][POSITIVE] Right. You're welcome. You too.
[AGENT][NEUTRAL] Bye.