AccountId: 011433970860
ContactId: 2e33a54a-c844-43fe-b2c9-4174e496a929
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 431279 ms
Total Talk Time (AGENT): 152089 ms
Total Talk Time (CUSTOMER): 215312 ms
Interruptions: 3
Overall Sentiment: AGENT=1.2, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/18/2e33a54a-c844-43fe-b2c9-4174e496a929_20250218T16:37_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling ATL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], it's [PII] calling from Multiplan. How are you?
[AGENT][POSITIVE] I'm doing well how are you?
[CUSTOMER][NEUTRAL] I'm well, thank you. I'm calling in reference to a claim that was submitted to us by a facility where they received the remittance and the remittance appears, it's it's formatted in a different way than the usually the explanation of benefits or the remittances that we see are in the fact that it doesn't account for all the bill charges.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And nor does it list whether multiplan was used for processing of the claim, like the um ID patients ID card um list that there it's a multi-plan limited benefit plan but does have access to the network, and I know that not all patients have access to the network in all states of the [PII]. So I'm just calling to see if this claim was in fact processed as a multi-plan claim because we did receive it for pricing, we did return pricing.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, because the facility is a participating facility, but the remittance just doesn't seem to account for all of the details.
[AGENT][NEUTRAL] OK. OK.
[CUSTOMER][NEUTRAL] So may I give you the claim number or the patient's details or so I can try and get this reconciled for the hospital, which would be more helpful, the claim number?
[AGENT][NEUTRAL] Of course.
[AGENT][POSITIVE] Absolutely. I'm sorry.
[AGENT][POSITIVE] Really quick, I'm so sorry you did say your name was uh [PII], is that right?
[CUSTOMER][NEUTRAL] I did, yes.
[AGENT][NEUTRAL] OK, and then, um, can I get a a good call back number from you in case we're disconnected please?
[CUSTOMER][NEUTRAL] Sure, sure, it's direct, it's [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] OK, thank you and then um yeah I could just take that claim number is perfectly fine.
[CUSTOMER][NEUTRAL] Sure, it's 355-8043.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Patient's name is [PII].
[CUSTOMER][NEUTRAL] I'm so sorry if I mispronounce this.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, thank you. Do you have uh the date of birth?
[CUSTOMER][NEUTRAL] I do. What was billed on the claim is [PII].
[AGENT][POSITIVE] Perfect. OK, yes, thank you for verifying that. All right, let's take a look here.
[CUSTOMER][NEUTRAL] And this was the date of service from [PII] at Texas Health Fort Worth for total bill charges of 4,316,410, and it appears as though the remittance is accounting for $700.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Right, I do show that that's the amount that the the paid benefit amount that we paid.
[CUSTOMER][NEUTRAL] Right, so I'm just wondering if the multi plan um.
[CUSTOMER][NEUTRAL] A loud amount of.
[CUSTOMER][NEGATIVE] I'm just trying to get in here to the pricing again. We returned pricing for a total allowed of 37,55278 for a discount of 5,61132.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So was this processed with the multi-plan pricing?
[CUSTOMER][NEUTRAL] But in accordance allowing for the patient's benefit of $700 because as you can see, or maybe not, maybe you have a different formatted explanation of benefits, the one that was sent to the facility and the one that was forwarded to us with this case is only account like the total bill charges aren't on there. It only shows a paid amount of $700.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Oh, I OK, I see what you're saying. OK, um, [PII], if you don't mind, I'm going to put you on a brief hold. I kind of just see surface level for these claims, so I'm going to reach out to our claims specialist, uh, so they could take a look and um we'll get it figured out. Give me just a moment, OK?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Or if there's a or if there's a reformative explanation of benefits that accounts for everything that could be forwarded to me, that would be amazing.
[AGENT][NEUTRAL] Let me see, um, again I'm not quite sure if I've got access to that, but let me just check real quick.
[CUSTOMER][NEUTRAL] What I I may have to come from them, but I just thought I'd ask that. I just wanted to ask that question as well.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Sure, I can check really quick. Give me just a moment.
[CUSTOMER][POSITIVE] Thank you so much, [PII].
[AGENT][NEUTRAL] Of course.
[AGENT][NEUTRAL] OK, yeah, that is all I'm seeing too is basically what adds up to that 700. So yeah, I'm gonna go ahead and put you on that brief hold, [PII] and I'll reach out to our claims specialist. I'll get right back with you, OK? Of course, one moment.
[CUSTOMER][POSITIVE] Thank you so much, thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Ferring
[CUSTOMER][POSITIVE] Good morning thank you for calling APL. This is [PII]. How may I help you?
[AGENT][NEUTRAL] Hey [PII], this is [PII] over on the care team how are you?
[CUSTOMER][NEUTRAL] Fine, how are you?
[AGENT][NEUTRAL] Alright thank you I've got a provider needing to talk to y'all um she well actually she said she's with Multiplan um she's calling regarding a claim for uh HI and frankly I'm a bit confused as to what I, I believe she wants a more detailed EOB um she has an EOB showing the benefit amount that we paid, but I think she's wanting a more detailed one with the total charges versus what we paid.
[CUSTOMER][NEUTRAL] What's the policy number?
[AGENT][NEUTRAL] It is 02574226.
[AGENT][NEUTRAL] And it is for uh part one I do have that claim number.
[CUSTOMER][NEUTRAL] What's the claim number?
[AGENT][NEUTRAL] It's 3558043.
[CUSTOMER][NEUTRAL] So since this is an indemnity policy, this is how benefits are processed in a system, there's not any other there this is as detailed as the, the EOBs get that we that they processed.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That's what I figured um she was asking specifically if we used multi plan pricing but I mean it just goes off of our policy doesn't it?
[CUSTOMER][NEUTRAL] Right, even with the multi plan is based off the policy provisions, it only covers the indemnity amount outlined under the policy.
[AGENT][NEUTRAL] That's what I thought. I've just never had a somebody asked me that before, so I was like I have no idea. Would you mind explaining that to her?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Sure, you can send it to me. What's her name?
[AGENT][POSITIVE] Thank you, [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] All right, thank you. Are you ready for her now?
[CUSTOMER][POSITIVE] You're welcome. Yeah, I'm ready.
[AGENT][NEUTRAL] OK bye bye.