AccountId: 011433970860
ContactId: 2187242a-849d-4afb-b06f-6beb197b114c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 483309 ms
Total Talk Time (AGENT): 132715 ms
Total Talk Time (CUSTOMER): 269088 ms
Interruptions: 1
Overall Sentiment: AGENT=0.5, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/03/2187242a-849d-4afb-b06f-6beb197b114c_20250103T19:05_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, I'm sorry, your name was?
[AGENT][NEUTRAL] And the cleaning.
[CUSTOMER][NEUTRAL] How are you doing today? My name is [PII].
[AGENT][POSITIVE] Good. How are you, [PII]?
[CUSTOMER][NEUTRAL] Last name
[CUSTOMER][NEUTRAL] I'm good, thank you. I'm just calling in regards to um an explanation of benefits. Um, there's a couple remarks on, um, the statement I got back and I was curious as to um what's the issue.
[AGENT][NEUTRAL] Um, yes, ma'am. I can assist you with claim status. Um, first, could I get a good callback number just in case we're disconnected?
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] That's
[CUSTOMER][NEUTRAL] [PII] it's a direct line.
[AGENT][NEUTRAL] Thank you. Now, can I get the policy number, please?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] My policy number is 02282068.
[AGENT][NEUTRAL] OK. Thank you. Now, please verify your first and last name and your date of birth.
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][NEUTRAL] OK. And please verify your mailing address and your email address.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Uh, your mailing address [PII], I gave my telephone number [PII].
[AGENT][NEUTRAL] OK, thank you. And the claim number you're calling about?
[CUSTOMER][NEUTRAL] Um, give me one second, they're all listed on one claim number. It's going to be 3543949.
[AGENT][NEUTRAL] OK, yes, ma'am. And which charge are you calling about? or charges you're calling about?
[CUSTOMER][NEUTRAL] So there's there's 4 on here because I'm, I'm the practice manager so I helped her submit all of the um the claims. So, uh, [PII] 24 to Modi [PII], um, the remark says 1, but on the back of the EOB there's no remarks listed, so I don't know what the explanation is on that, but that one paid 0.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] And what was the date of service again on that one?
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, is it for the $220 charge for the office visit?
[CUSTOMER][POSITIVE] Yes, that's, that's correct.
[AGENT][NEUTRAL] Oh, yes, ma'am. That covered because under the, this policy, um, office visits not, is not covered. Um, treatment provided in the office is covered, but the co-pay for the visit, that's not covered.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK, cause they actually didn't process this at all cause they told her that they were in network with our primary insurance and then when she went there after the fact and they told her that uh they don't take our insurance so that wasn't actually a copay, it was uh a total charge. So does that come into consideration at all?
[AGENT][NEUTRAL] Um, no, ma'am. It doesn't. Um, as long as it was for an office visit, right, it's not covered.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, um, the second one was provider service first Path LLC [PII] Independent lab, and that also has a remark of number 2, but I don't know what the remark is and it pays 0.
[AGENT][NEUTRAL] OK, OK.
[AGENT][NEUTRAL] OK, I'm showing that that one denied because according to the primary carrier's ELB it shows that the primary carrier did not cover that charge. And if the primary carrier doesn't cover a charge, then we don't cover it either.
[CUSTOMER][NEUTRAL] You remember what that was on them LCC that's 1027. That's when I was at the hospital.
[CUSTOMER][NEUTRAL] Um, that's when I was there for my stomach issues.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK, so even that was, uh, I'm, I'm not sure what you mean but that wasn't covered by our primary cause labs are covered by our primary.
[AGENT][NEUTRAL] Yeah, well, according to the explanation of benefits, it was for um the lab, um, the charge was $113 even.
[AGENT][NEGATIVE] And it's showing that the primary carrier didn't cover it.
[CUSTOMER][NEGATIVE] I lost that one.
[CUSTOMER][NEUTRAL] OK, I'll go back and find that one. the next one in question is the, um, 1025 24 Phoenix emergency medicine.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] And that one says exclamation 3, remark number 3, but I don't know what that one is either.
[AGENT][NEUTRAL] OK, let's see.
[CUSTOMER][NEUTRAL] I can't find that first.
[CUSTOMER][NEUTRAL] Yes
[AGENT][NEUTRAL] OK, for that one, I'm showing that um the benefit maximum was reached um under this policy for outpatient services, we cover up to $500 per day and the benefit was maxed out on a previous um injury.
[CUSTOMER][NEUTRAL] Just
[CUSTOMER][NEUTRAL] Oh, from the ER copay probably OK, I see another claim for that same data service. I see what you're saying, um.
[CUSTOMER][NEGATIVE] And then the, the last one that I'm in question on is [PII], same day of service Broward Health. I'm sorry, uh, scratch that wrong date [PII]. It was an ER visit to Broward Health Coral Springs supposed to be reimbursed at $500 but it looks like they only paid $43798.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] They're gonna say there's another data service. It is they're combining the dates of service, so everything done in that same day, it's only payable up to $500 per day versus per visit. I'm sure that's what she's gonna tell me because I'm seeing now we have two other dates of service for [PII] which are gonna probably equal.
[CUSTOMER][NEUTRAL] 5062, yeah 6202437 is gonna come to the 500. Did I just explain that to myself?
[AGENT][NEUTRAL] Yes, you did.
[CUSTOMER][NEUTRAL] OK, alright, fair enough. Can we try to, um, find this one she said for the first pass you said it was 113 uh bill charge.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] And said it wasn't covered by, uh, that one we already went over is [PII]. That's the one with the remark of number 2.
[AGENT][NEUTRAL] Let's see, what was the date of service?
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Can't do it and I'm marking them off like marking them here, but.
[AGENT][NEUTRAL] OK. Yes, ma'am. That's the one that's showing that the primary insurance did not cover the charge. So, therefore, we denied it also. Now, if you have an updated explanation of benefits showing that the primary insurance paid something and something went towards the copay, the co-insurance or deductible, you can resubmit it.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I'm sorry, I'm just trying to find it in all my trying to find the EOB that I attached with. Oh, here it is. It was denied. Oh, OK.
[CUSTOMER][POSITIVE] Hm, what it's interesting.
[CUSTOMER][NEUTRAL] Yeah, see, this is when I was in the hospital for the lower thing, and for some reason they're denying unless they use the wrong lab. The only thing I can think is the hospital sent those to the wrong lab, and that's why it was denied, but they didn't send you a bill as of yet, right? No, no, I don't believe so. OK, alright, um, I think that was all of our questions. I, I appreciate your explanation.
[AGENT][POSITIVE] OK, no problem. Is there anything else that I can assist you guys with?
[CUSTOMER][POSITIVE] No, I think that's it. Do you have any questions? No, thank you so much. [PII].
[AGENT][POSITIVE] [PII] to y'all too. Thank you for calling ATL. Mm bye.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Yes ma'am.