AccountId: 011433970860
ContactId: 2e886fb2-ac64-49da-a4c6-80e9bf1a92fc
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 926400 ms
Total Talk Time (AGENT): 190501 ms
Total Talk Time (CUSTOMER): 279145 ms
Interruptions: 1
Overall Sentiment: AGENT=0.8, CUSTOMER=-0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/28/2e886fb2-ac64-49da-a4c6-80e9bf1a92fc_20250428T14:02_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII], this is [PII] reaching out from a provider's office um in in regards to a patient.
[CUSTOMER][NEUTRAL] And a claim
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and [PII], what is your callback number please?
[CUSTOMER][NEUTRAL] Is area code [PII]?
[AGENT][NEUTRAL] And what is the policy number, please?
[CUSTOMER][NEUTRAL] Um, outpatient benefit number is 01666110ML8.
[AGENT][POSITIVE] Thank you, one moment.
[AGENT][NEUTRAL] I verify the patient's name and date of birth.
[CUSTOMER][NEUTRAL] Is [PII], last name [PII] Date of birth [PII].
[AGENT][NEUTRAL] Thank you for verification and again your contact, yes thank you and your claim status I can assist you. What is the date of service and the total charge amount please?
[CUSTOMER][NEUTRAL] He's a spouse.
[CUSTOMER][NEUTRAL] Uh, so this was 9-1924.
[CUSTOMER][NEUTRAL] Total bill amount was 9,521.
[AGENT][POSITIVE] OK, thank you so much. One moment please, and just to repeat that was [PII] for $9,521 even.
[CUSTOMER][NEUTRAL] Uh yes.
[CUSTOMER][NEUTRAL] I don't know if you want the backstory on this I guess the patient must have spoke with APL on Friday as well um so typically the.
[CUSTOMER][NEUTRAL] The care center, Doctor [PII]'s office, um, has the patient submit on their, on their own for reimbursement.
[CUSTOMER][NEUTRAL] So the patient called me this morning and stated that APL is saying they paid, APL paid Dr. [PII]'s office $400.
[CUSTOMER][NEUTRAL] And I don't, I'm not showing a payment of $400 to Doctor [PII] or [PII], um, for hit the professional charges.
[AGENT][NEUTRAL] OK, so you have a claim number associated with that. I was still searching for the claim. Do you have a claim number on, [PII]?
[CUSTOMER][NEUTRAL] Not APL's claim number no.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, one moment.
[AGENT][NEUTRAL] So it's $9,521 OK.
[AGENT][NEUTRAL] OK, so you're looking for the payment of money, $521. OK, give me one.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And the 9, excuse me, 9,521 were the professional fees, is that correct and not the facility?
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And may I place you on a brief hold please, [PII]? I'm just look up on the notes.
[CUSTOMER][POSITIVE] Sure take your time.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Thank you so much for your patience, [PII]. We do not have a claim on file for the professional fee for $9,521. We have not received that from, and the doctor's name again, please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Doctor [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] No, we do not have that claim on file, so a claim was not paid to Doctor [PII], excuse me.
[CUSTOMER][NEUTRAL] Um, and just to confirm, um.
[CUSTOMER][NEUTRAL] Our tax ID will show Ortho Florida LLC and Doctor [PII] being the surgeon.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] We have not received a claim for the professional fee for Doctor [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] No, ma'am.
[CUSTOMER][NEUTRAL] So he's very adamant that the $400 payment was sent to us.
[AGENT][NEUTRAL] We
[CUSTOMER][NEUTRAL] The patient, um, husband.
[AGENT][NEUTRAL] No, um, now we may have received a claim from the facility but not from.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] OK. I was trying to explain that to him that there are multiple entities when you have a surgery and could it possibly have been Miami Surgical Center, which sounds a lot like Miami, um, um, Miami sports medicine, or, you know,
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I guess my next question, just to confirm before I, before I call the patient back, um, this particular surgery charge for the professional fees, the patient was responsible for a $150 co-pay for surgery for Doctor [PII].
[CUSTOMER][NEUTRAL] That's this policy.
[CUSTOMER][NEUTRAL] Cover that portion.
[AGENT][NEUTRAL] Now what the benefits are for the member of.
[CUSTOMER][NEUTRAL] If it was submitted.
[AGENT][NEUTRAL] OK, give me one second, and you're asking what the benefits are, is that correct?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, one moment, [PII].
[AGENT][NEUTRAL] The benefits
[CUSTOMER][NEGATIVE] Sorry, I just wanna have my thoughts do my eyes and tears with him because I, I feel terrible, but I I I'm giving him.
[CUSTOMER][NEUTRAL] All the information I can.
[AGENT][NEUTRAL] OK, OK, give me one second. It may be my phone, but your voice is um choppy. Give me one moment please. Let me just adjust my headphone please. Just bear with me.
[AGENT][NEUTRAL] Bear with me. OK, all right.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I think I can hear you better. OK, so for the benefits for this member, um, please note verification of benefits provided does not guarantee payment. They pay on a per day max, so for per day we will pay up to $500 per calendar day.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So with that being said, if the $400 was for the facility, then there would be an additional $100 that the payment, or that the patient could be reimbursed for that particular date of service.
[AGENT][POSITIVE] Um, that is correct. It all depends. That is correct. That is correct. And the ideal situation we pay up to $500 per day.
[CUSTOMER][NEUTRAL] OK. OK.
[AGENT][POSITIVE] The ideal situation.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I'm gonna reach back out to the husband and um I'll gather his information for Blue Cross Blue Shield for Doctor [PII]'s portion and if he'd like to submit that to APL to receive the other 100.
[CUSTOMER][NEUTRAL] And he needs to reach out to the surgery center, I guess.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And again, you said, I can hear you better now, Doctor [PII], his professional fee was $9,521.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, and we do not have that claim on file so that claim is not on file, OK?
[AGENT][NEUTRAL] Doctor [PII].
[CUSTOMER][NEUTRAL] And maybe what he did, I don't know, maybe the patient submitted our receipt.
[CUSTOMER][NEUTRAL] With the surgery centers.
[CUSTOMER][NEUTRAL] HCA form.
[CUSTOMER][NEUTRAL] Or if the er I, I
[CUSTOMER][NEUTRAL] Um, I don't
[CUSTOMER][NEUTRAL] He's, he's, I guess a little upset, so maybe he's um
[CUSTOMER][NEUTRAL] I don't know.
[CUSTOMER][NEUTRAL] I don't know. I'm just trying to make him happy and figure out, you know, where the payment went because he he's being very adamant that we received that check and I'm not showing that at all, so.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] No, ma'am, we, um, we don't have a claim on file for Doctor [PII] for that date of service for that total charge amount.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Perfect. He said he was gonna forward over some information to me via email, so I'll wait to receive that overlook it, make sure what we've discussed is what he's sending to me and then I could just kind of point out exactly where the 400 went and where he needs to go from here and hopefully that will work.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. I'm sorry. I can't give you more information, Ms. [PII], but I do say I, I can say.
[CUSTOMER][POSITIVE] No. Oh, no, no, that was helpful.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Um, is there a reference number for our call?
[AGENT][NEUTRAL] You can use my name, [PII], last initial is [PII], and today's date.
[CUSTOMER][POSITIVE] Beautiful. Thank you, [PII]. I hope you have a fabulous Monday. I appreciate all your help.
[AGENT][NEUTRAL] Mhm
[AGENT][POSITIVE] You're welcome, Miss [PII] and same to you and thank you for calling us APL.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright bye bye.
[AGENT][NEUTRAL] Bye.