AccountId: 011433970860
ContactId: 24323045-411e-45c5-a6a0-97d085005c85
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1109280 ms
Total Talk Time (AGENT): 372959 ms
Total Talk Time (CUSTOMER): 445902 ms
Interruptions: 5
Overall Sentiment: AGENT=0.1, CUSTOMER=-0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/24/24323045-411e-45c5-a6a0-97d085005c85_20250324T18:16_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Yes, [PII], good afternoon. This is [PII] calling from Sinai Medical Center. I need to verify if you guys were claimed for a member.
[AGENT][NEUTRAL] OK, I can definitely check and see if the claim has been received for you. And [PII], may I have a good contact number in case we disconnected?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] Yes, policy number, it is 02199664.
[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] [PII], [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 you like me to look for?
[CUSTOMER][NEUTRAL] Um, [PII].
[CUSTOMER][NEUTRAL] With the bill amount of 5,87548.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] And what is the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] Mount Sinai Medical Center.
[AGENT][NEUTRAL] Alright, so I'm showing we received the claim on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The claim number is 355.
[AGENT][NEUTRAL] 4642.
[AGENT][NEUTRAL] And on [PII], the claim was denied, I'm sorry, 2025.
[AGENT][NEUTRAL] The claim was denied requesting the explanation of benefits from primary insurance.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, give me a second. What would be the reference number?
[AGENT][NEUTRAL] So there's no call reference number, but you can use my name in today's date, and that's [PII], [PII] initial to my last name is [PII].
[CUSTOMER][NEUTRAL] OK, I do have another member. Give me a 2nd. [PII].
[CUSTOMER][NEUTRAL] OK, yeah.
[CUSTOMER][NEUTRAL] Member ID number is 0182. OK, OK.
[AGENT][NEUTRAL] Oh, hold on, hold on one second. Uh, hold on one moment.
[AGENT][NEUTRAL] Let me um note this policy and then I can move to the next one.
[AGENT][NEUTRAL] OK, and the next member's policy number?
[CUSTOMER][NEUTRAL] 01823108.
[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] [PII] [PII].
[AGENT][NEUTRAL] Thank you. And again, just for the call, the information provided with a verification of benefits, not a guarantee of payment. And may I have the um
[AGENT][NEUTRAL] Data service for the claim?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And the total bills?
[CUSTOMER][NEUTRAL] So the amount, it is 15,624 23 cents.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] Alright, so I'm showing we received the claim on [PII].
[AGENT][NEUTRAL] The claim number is 357.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 4380.
[AGENT][NEUTRAL] And on [PII], the claim was denied.
[AGENT][NEUTRAL] Um, in order for
[AGENT][NEUTRAL] In order for us to process this claim, we need the explanation of benefits that matches the claim information, so the wrong explanation of benefits was received.
[CUSTOMER][NEUTRAL] Really, because I was the one sending the explanation of benefits.
[AGENT][NEUTRAL] OK, I can pull up the documents. Let's see, hold on one moment.
[CUSTOMER][NEUTRAL] On the
[CUSTOMER][NEUTRAL] Let me go ahead and get the, that's what I was going to do.
[CUSTOMER][NEUTRAL] It was on [PII] that it was sent.
[CUSTOMER][NEUTRAL] OK, for.
[AGENT][NEUTRAL] OK, hold on one second.
[CUSTOMER][NEUTRAL] So there are two lines. The first one, it says 451, but if you guys scroll down to service line details, all over on the bottom, it says
[CUSTOMER][NEUTRAL] The same member with the status.
[CUSTOMER][NEUTRAL] Um, with the data of service, and it says facial responsibility 1,269.
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] Wait
[AGENT][NEUTRAL] Do you mind if I place you on just a brief hold?
[CUSTOMER][POSITIVE] Sure, thank you.
[AGENT][NEUTRAL] Alright, you're welcome hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] I understand what she's saying, but the data service on here, OK, right, but that, OK, thank you.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Hello [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] All right, thank you so much for holding. So yes, on the explanation of benefits, I do see the December, I'm sorry, December [PII] to [PII] data service, but
[AGENT][NEUTRAL] Of the four pages that you submitted, the first page was the claim form, and the date of service on this claim form for these charges is [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] So the date
[CUSTOMER][NEUTRAL] So first it's going to be.
[CUSTOMER][NEUTRAL] Um, [PII], if you go down more down, it, it is the date of service [PII]. It's all over on the bottom page for UHC.
[AGENT][NEUTRAL] OK, so then we need to receive that page because from what we received.
[CUSTOMER][NEUTRAL] It is in there.
[AGENT][NEGATIVE] OK, I'm just gonna let you know what we received, because there's only one. So I scrolled all the way down to the bottom of this page, I've gone to the next page. Now it is written over, but there's no more dates of service on this second page here. It says admission date [PII], discharge date [PII]. There's nothing on here what we received that mentions [PII].
[CUSTOMER][NEUTRAL] OK, hold. So there is
[CUSTOMER][NEUTRAL] OK, there is this um the cover page.
[CUSTOMER][NEUTRAL] The UVO 4, there are 2 pages.
[CUSTOMER][NEUTRAL] And then the United Healthcare provider remittance advice. Yes, it's going to be for data service, 16 through 17. But if you scroll down more down, it will be there, it's one whole entire page of the United Healthcare. We cannot divide that because it's all come together.
[AGENT][NEUTRAL] OK. Well, I can see if there's a claims um examiner available to look at these documents because on what we received it, it doesn't mention the [PII], but I can have an examiner look at this with you if you'd like.
[CUSTOMER][POSITIVE] Go ahead. Thank you.
[AGENT][POSITIVE] You're welcome. Before I transfer you over, was there anything else I could assist you with today?
[CUSTOMER][NEUTRAL] No, no, that was so.
[AGENT][NEUTRAL] All right, [PII], hold on one moment while I get a claims rep for you, OK?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] I could have helped her, but I'm gonna do what she said.
[AGENT][NEUTRAL] And they changed the whole tone of the call.
[AGENT][NEUTRAL] But OK.
[AGENT][NEUTRAL] Well
[CUSTOMER][NEUTRAL] Ferring
[CUSTOMER][NEUTRAL] afternoon thank you for calling APL. This is [PII]. How may I help you?
[AGENT][NEUTRAL] Hey, [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 um provider on the other line. We were going over a claim status. So basically we need the explanation of benefits that they sent in doesn't match the data service. I've gone through all the documents with her that we received in Onase and she's still telling me that we did receive it, um.
[AGENT][NEUTRAL] So, can you help me with this?
[CUSTOMER][NEUTRAL] What's the policy number?
[AGENT][NEUTRAL] It's 182-3108.
[CUSTOMER][NEUTRAL] Um, [PII].
[AGENT][NEUTRAL] Laser, mhm.
[CUSTOMER][NEUTRAL] River
[CUSTOMER][NEUTRAL] And what claims, what is the, the claim?
[AGENT][NEUTRAL] That first or the last claim there 357-438-0?
[CUSTOMER][NEUTRAL] Number.
[CUSTOMER][NEUTRAL] OK, let me see.
[CUSTOMER][NEUTRAL] For [PII]?
[AGENT][NEGATIVE] That's what the claim form say. She's saying that it's supposed to say the [PII] and I'm like, well, we haven't received that.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And she's like, well, we can't break up the forms, and I'm like, well,
[CUSTOMER][NEUTRAL] OK, let's see here.
[CUSTOMER][NEUTRAL] And did you verify the pro is the provider Mount Sinai Medical Center?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And she said it should be a [PII] day of service?
[AGENT][NEUTRAL] Yeah, like the explanation of benefits does say [PII], and that's the date of service she gave when she called for the claim status, but the claim form she submitted says [PII]. We don't have anything for the [PII].
[CUSTOMER][NEUTRAL] Oh, OK, I see what you're saying. OK, so we got a UB for [PII], but the UOB is for [PII]. OK, I see.
[CUSTOMER][NEUTRAL] And that's what you explained to her that we have a E the EOB and a UB is two different things.
[AGENT][NEGATIVE] Don't match, right? And she's like, well, on the claim form, if you scroll all the way down, you'll see [PII] and [PII], and I'm like, well, I've scrolled to the bottom. I don't, we haven't received it.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So let me see.
[AGENT][NEUTRAL] So she's wanting to speak to a um claims examiner for, for more, I guess.
[CUSTOMER][NEUTRAL] And it looks like it might have been cut off. Cause if you, if you look, mhm.
[AGENT][NEUTRAL] Right, you see where it's like written on over.
[CUSTOMER][NEGATIVE] Yeah, I mean, cause that's all I'm gonna tell it looks like it was cut off, like maybe there should have been another page sent but it was cut off. It only shows us the received date. It doesn't show us the date of service. Oh no, wait, it does.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It is. The data service is there. It is there right at the bottom you see where it says claim date [PII].
[CUSTOMER][NEUTRAL] And the charge amount is for $15,624.23. So yeah, it is there but it.
[AGENT][NEUTRAL] The bottom of, of what?
[CUSTOMER][NEUTRAL] Of page 4.
[AGENT][NEUTRAL] 04.
[CUSTOMER][NEUTRAL] But it does, yeah, it does, it is cut off still though because
[CUSTOMER][NEUTRAL] It looks like there should be the continuation of this EOB.
[CUSTOMER][NEUTRAL] Because it shows patient responsibility. However, it looks like the page is part of the EOB that will show.
[AGENT][NEUTRAL] Oh, I see what you're saying. Mhm.
[CUSTOMER][NEGATIVE] Yeah, it looks like the part where it would show where that amount was applied towards that part is cut off.
[AGENT][NEUTRAL] But still, even though it says the claim date is 1/12, these charges are for 1/6. So we still need the EOB or even the claim form that matches.
[CUSTOMER][NEUTRAL] It's two different ELBs.
[CUSTOMER][NEUTRAL] Yeah, it's two different EOBs, so that's where it looks like she did submit it. She did submit it, but it looks like it's cut off for 11/12, I mean 112 is what I'm saying, cause it, it shows the different claim numbers on the top. If you look at that 16, it has a different claim number there and then we look at the 112, it has a different claim number there.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Where it has the EW 28166076, when you look at that claim number.
[CUSTOMER][NEUTRAL] On page 4.
[AGENT][NEUTRAL] Hold on.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Oh, I see what you're saying. Yes, OK. Whoa.
[CUSTOMER][NEUTRAL] OK, yeah, so where it says claim date 106, then it has that claim number that's for the 106, when you scroll all the way to the bottom, then it has that claim date 112-25 and that claim number is two different ones and it has that charge amount for the you be on page two.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] But it looks like page 43 might be missing cause it's like it might continue. Yeah.
[AGENT][NEUTRAL] Missing.
[CUSTOMER][NEUTRAL] So I will let them know we got a partial of the we didn't get the full pages of the EOB for the [PII] data service.
[CUSTOMER][NEUTRAL] Cause it looks like did they fax this.
[AGENT][NEUTRAL] But, but what she's saying, but she doesn't want the 12, she wants the 6.
[CUSTOMER][NEUTRAL] Yeah, it was it's facts.
[CUSTOMER][NEUTRAL] OK, so on the 6th, OK, let me pull up because like we got something we paid something for the 6th. Let me look at this generator 6 data service that we already paid. Let me see if it's the same claim.
[AGENT][NEUTRAL] So we either need to get a
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Which was processed on the 3rd, let me pull that up real quick.
[CUSTOMER][POSITIVE] No I'm sure that I bet this is what it is too.
[CUSTOMER][NEUTRAL] So, 16.
[CUSTOMER][NEUTRAL] See if it's the same bill amount of of this EOB.
[CUSTOMER][NEUTRAL] OK, let's see 16 looks like the bill amount was for.
[AGENT][NEUTRAL] Wait a minute, wait a minute, wait a minute, wait, wait, wait.
[CUSTOMER][NEUTRAL] OK, so this one is.
[AGENT][NEGATIVE] I think I got it mixed up. She's calling about the 12th. The claim form says the 12th, the EOB says the 6th and the 7th. That's the problem, OK. I had to get it straight.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, yeah, OK, so she is in fact calling about the 12th regarding the UB that we did. OK, so yeah, it looks like we did receive partial of the EOB for the 12th.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEGATIVE] It looks like page 43 is missing, like the continuation of the EOB.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Do you see what I'm looking at?
[AGENT][NEUTRAL] Yeah, I'm looking, I see it and then I and I see down at the bottom where it says 42 or 50. Yeah, I'm following you.
[CUSTOMER][NEUTRAL] OK, yeah.
[CUSTOMER][NEGATIVE] Yeah, and it looks like the patient responsibility is 1269, but it looks like the full EOB is missing.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEGATIVE] So it looks like maybe it should have there should have been a page 43 possibly that it continued on.
[AGENT][NEUTRAL] With showing those charges. OK.
[CUSTOMER][NEUTRAL] Mhm. For the 112.
[CUSTOMER][NEUTRAL] Yeah, I was advise him to resubmit the EOB for 112 because like we received partial of that page.
[AGENT][NEUTRAL] Well, she wants to talk to you.
[CUSTOMER][NEUTRAL] That's fine. I can explain it to her.
[AGENT][NEUTRAL] OK, um, hold on one.
[CUSTOMER][NEUTRAL] And what's her name?
[AGENT][NEUTRAL] I was about to say [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, hold on one second, all right.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Hello, [PII].
[AGENT][NEUTRAL] Hello [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Hi, 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