AccountId: 011433970860
ContactId: 29c36436-b5e9-4dc9-8001-e459ae864aef
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 313239 ms
Total Talk Time (AGENT): 142353 ms
Total Talk Time (CUSTOMER): 165381 ms
Interruptions: 3
Overall Sentiment: AGENT=2.3, CUSTOMER=1.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/10/29c36436-b5e9-4dc9-8001-e459ae864aef_20250210T13:57_UTC.wav
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[AGENT][NEUTRAL] Good morning. Thank you for calling APL. This is [PII] speaking. How can I help you?
[CUSTOMER][POSITIVE] Hey [PII], how are you doing today?
[AGENT][POSITIVE] I'm doing well [PII] thank you how are you?
[CUSTOMER][POSITIVE] I'm doing all right for a Monday.
[AGENT][NEUTRAL] Uh yeah
[CUSTOMER][NEUTRAL] I have got a provider on the line. We've been going over and over, uh, around and around and in and out about an EOB and she's fine. She just doesn't understand and I've explained every way I can. It's on policy number 243.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Got you.
[CUSTOMER][NEUTRAL] 2958
[CUSTOMER][NEUTRAL] For [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I have [PII] on the line. Her callback number is [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Um, it's regarding claim 3557918.
[CUSTOMER][NEUTRAL] This is an EOB that she sent in on a prior request from a claim, and I keep telling her, you know, that the offices it's not covered. She's fine with that. The EOB shows a co-pay, but it doesn't even show what procedure the copays toward, and then she does have the office treatment [PII]. I keep trying to tell her we need a detailed EOB showing the deductible copay or co-insurance for each of those procedures, she says that.
[CUSTOMER][NEUTRAL] I close up that image, the development, whatever it was, development, they process all the claims for HMO for Blue Cross, so she can't get she said there won't be an EOB from Blue Cross.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEGATIVE] And she doesn't know how to get what we need for those procedures.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] She just doesn't unders.
[CUSTOMER][NEGATIVE] She says, I just don't understand. And I've tried, you know, from every angle, and I don't know.
[CUSTOMER][NEUTRAL] If maybe you can
[CUSTOMER][NEUTRAL] Maybe you're the magic touch today.
[AGENT][NEUTRAL] Yeah, let's hope so. Is that her, um, you said [PII], right? OK, and it's dermatolog this dermatology it looks like associates or something, OK, and.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, dermatology Associates.
[AGENT][NEUTRAL] I'm looking at it as well and I don't see.
[AGENT][NEUTRAL] I can um I can try to talk to her. I'm not sure exactly what I can tell her either so I'm I'm looking for the copay line but I don't see it.
[CUSTOMER][NEUTRAL] So that's what I was trying to tell her, even though they had the copay listed, it doesn't tell us what.
[AGENT][NEUTRAL] What, which one it's directed for. My guess is it's probably the office visit because that's usually um
[CUSTOMER][NEUTRAL] Procedure it was applied to, yeah.
[CUSTOMER][NEUTRAL] That's, that's what she said.
[AGENT][NEUTRAL] Because it doesn't say co-insurance and or deductible, it just says copay, so that's the office is a co-pay.
[CUSTOMER][NEUTRAL] Yeah, but she's keeps asking about those other two CPTs and how we can, what, what can she get.
[AGENT][POSITIVE] So, but I'll be happy to try to talk to her.
[CUSTOMER][NEUTRAL] I just, I just don't know how to explain it any other way.
[AGENT][POSITIVE] Exactly, right. Got you.
[AGENT][POSITIVE] I understand. I'll see what I can do.
[CUSTOMER][POSITIVE] All right. Thank you, [PII]. Let me get her on the line. Have a good day.
[AGENT][POSITIVE] You're welcome. You too. Thank you.
[CUSTOMER][POSITIVE] [PII], thank you for holding. I do have [PII] on the line and she's reviewing that claim and will assist you and you have a wonderful day. I appreciate it thanks so much have a good day bye bye.
[AGENT][NEUTRAL] Hi [PII], my name is [PII]. I'm in the claims department. How are you?
[CUSTOMER][POSITIVE] Yes ma'am, I'm doing well thank you how about yourself?
[AGENT][POSITIVE] Good thank you.
[AGENT][NEUTRAL] OK, so I have pulled up the um the claim information. [PII] was explaining to me that um she had told you that uh the offices it's not covered under this plan and that um there were additional procedures that uh you were looking for reimbursement for however the explanation of benefits or payments that was received.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And that, yes.
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] Um, doesn't show us a co-insurance and or deductible. So this policy is limited, uh, supplemental benefit plan, so it would require, um, that coinsurance and or deductible amount to show under the coinsurance and deductible line.
[AGENT][NEUTRAL] As member, uh, you know, applied to the member's copay or deductible, I'm sorry, co-insurance. Now I do see the copay is $60 but that looks like, um, of course when it's when it says copay, that's the office visit usually and then like I said, if there's any coinsurance and or deductible due that would show on that line and then we would then, uh, you know, process it as such.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][POSITIVE] Yes, correct.
[CUSTOMER][POSITIVE] All right, yeah, that makes sense. The the way she was explaining it to me was not making sense to me. I'm like, what are you talking about? Alright, well I appreciate your help. Thank you for looking into that for me and what was your name?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] My name is [PII].
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Perfect, uh huh, is there a reference number?
[AGENT][NEUTRAL] And then you
[AGENT][NEUTRAL] You use my name in today's date?
[CUSTOMER][POSITIVE] All right [PII], alright, thank you very much for your time you have a great day.
[AGENT][NEUTRAL] You too, [PII] did you have any other questions?
[CUSTOMER][POSITIVE] No ma'am, that'll be it thank you so much.
[AGENT][POSITIVE] Thank you for calling APL. I hope you have a great rest of your day and a great week.
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][POSITIVE] Thank you