AccountId: 011433970860
ContactId: 33e22155-e954-4771-abda-53aae31bead9
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 736770 ms
Total Talk Time (AGENT): 265727 ms
Total Talk Time (CUSTOMER): 235496 ms
Interruptions: 2
Overall Sentiment: AGENT=0.6, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/10/33e22155-e954-4771-abda-53aae31bead9_20250310T16:59_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], uh, my name is [PII]. I'm calling from Golden Orthopedics. I have a question on a claim that was paid, um, and I just, I had a question regarding that.
[AGENT][NEUTRAL] OK, so you have a question regarding a claim that was processed with the benefit paid, is that correct?
[CUSTOMER][POSITIVE] Correct.
[AGENT][POSITIVE] Uh yes, ma'am. I can help you with that. And I'm so sorry though. What is your first name again?
[CUSTOMER][NEUTRAL] Yeah, my name is [PII]. It's [PII]
[AGENT][NEUTRAL] OK, [PII], thank you, and your callback number, please?
[CUSTOMER][NEUTRAL] Yeah, it's uh [PII].
[AGENT][POSITIVE] Thank you and the member's policy number, please.
[CUSTOMER][NEUTRAL] 994486
[AGENT][POSITIVE] OK, [PII], thank you one moment please.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] OK, so any information that is provided would be a verification of benefits and not a guarantee of payment. What is your patient's name and date of birth?
[CUSTOMER][NEUTRAL] [PII], [PII].
[AGENT][NEUTRAL] OK. And you said it was 994486?
[CUSTOMER][NEUTRAL] 99 let's see, policy oh let me give you the policy number off of the EOB because that's what we have in here but when I look at your EOB, it is policy number is a little different it's it's.
[AGENT][NEUTRAL] That's
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yes, cause that policy number that you gave me does not pull that number up in our system.
[CUSTOMER][NEUTRAL] Yeah, here, let me give that to you it's 01912866 maybe that is the right one.
[AGENT][NEUTRAL] OK, one moment, please.
[AGENT][NEUTRAL] And I'm sorry, what was the patient's name again and date of birth?
[CUSTOMER][NEUTRAL] Yeah, it's [PII].
[AGENT][NEUTRAL] And date of birth?
[CUSTOMER][NEUTRAL] Date of birth is [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And what is the data service in total bill amount?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] For $2500.
[AGENT][NEUTRAL] Thank you and the claim number?
[CUSTOMER][NEUTRAL] Claim number is 328-71997.
[AGENT][NEUTRAL] OK thank you one moment please while I get this information pulled up.
[AGENT][NEUTRAL] And you did say the year is [PII], is that correct?
[CUSTOMER][NEUTRAL] Right, yes, that is.
[AGENT][POSITIVE] OK. All right, thank you.
[AGENT][NEUTRAL] OK and the name and again the name of the provider facility?
[CUSTOMER][NEUTRAL] Golden Orthopedics.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK, yes, ma'am. So how can I help you with that today?
[CUSTOMER][NEUTRAL] OK, so this is what's going on. So originally the primary insurance paid but applied a large amount to the deductible and then you guys paid your maximum benefit which was $250.
[AGENT][POSITIVE] That is correct. Yes, ma'am.
[CUSTOMER][NEUTRAL] And then
[CUSTOMER][NEUTRAL] After that, the primary insurance reprocessed the claim and paid.
[CUSTOMER][NEUTRAL] The claim they paid an additional amount and reversed the deductible amount so the the deductible was they had they came back and said oh no we we're gonna pay the deductible was already met. So then there was only a co-insurance of $46.10 due instead of that large deductible. So we tried to submit a corrected claim to you guys a couple times with those EOBs to show that.
[CUSTOMER][NEUTRAL] Um, the primary insurance reprocessed and that you pay too much with the $250 but they just deny it duplicate. So what is the process? How is that, should that be handled?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so what I'm gonna do is I'm gonna connect you with one of the examiners that works um with reviewing this because I can see that it has been received multiple times and denied as a duplicate.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So when I transfer you though, um, I will explain to them what has happened and so you did include the additional.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Uh, the corrected EOB from the primary insurance. Is that correct?
[CUSTOMER][NEUTRAL] Yes mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Yeah, so we need you guys, yeah, because there needs to be like a recruitment to you guys because it's now it's overpaid.
[AGENT][NEUTRAL] Yes, OK, so yes, that's what I'm gonna do, um, [PII], I will get you connected with someone who can further look at this with you since it has been submitted multiple times, OK.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] OK, great.
[AGENT][NEUTRAL] Alright, well, is there anything else that I could help you with before I do transfer you?
[CUSTOMER][POSITIVE] Um, nope, uh, that'll be it. Thank you so much.
[AGENT][POSITIVE] OK, OK. Well, you're welcome and thank you again for calling APL. I hope that you have a very uh nice afternoon. And if you will give me just one moment. All right, thank you. I appreciate that. I will get you transferred, OK?
[CUSTOMER][POSITIVE] Thanks you too.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK bye bye.
[AGENT][NEUTRAL] All right, bye bye.
[CUSTOMER][NEUTRAL] Ping
[CUSTOMER][POSITIVE] Good afternoon. Thanks for calling ATO. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hey, [PII], it's [PII]. How are you?
[CUSTOMER][POSITIVE] Oh, I'm good how are you?
[AGENT][NEUTRAL] I'm OK, thank you. So I have a provider's office on the line and it's regarding policy 1912866 and it's for part one, Mr. [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The lady I'm speaking with, her name is [PII].
[AGENT][NEUTRAL] And her callback number, [PII] is [PII].
[AGENT][NEUTRAL] And the claim number that she gave me was 328-719-7 for data service 322023 for him for 2500.
[AGENT][NEUTRAL] So we initially paid the 250 on the claim, the original claim. However, the primary insurance came back and there was an adjustment.
[AGENT][NEUTRAL] And they have sent.
[AGENT][NEGATIVE] The new explanation of benefits to us twice and those last two claims have been denied as a duplicate.
[AGENT][NEUTRAL] So she's trying to find out because she says that, you know, we overpaid on the claim at this point.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, give me, give me one second to pull that information up.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Yeah, sure. Uh-huh, sure.
[CUSTOMER][NEUTRAL] 6
[CUSTOMER][NEUTRAL] 51
[CUSTOMER][NEGATIVE] Come on, get your fingers together.
[CUSTOMER][NEGATIVE] Nobody probably didn't wanna request a refund. They ain't request a refunds, Lord [PII].
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] One second, I'm pulling it up.
[AGENT][NEUTRAL] Uh, OK. I just didn't want to do a hub ticket since they submitted it twice.
[AGENT][NEUTRAL] And it's an old claim.
[AGENT][NEUTRAL] I wasn't sure, you know.
[CUSTOMER][NEUTRAL] Oh yeah, we, yeah, let's see when was the process [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEGATIVE] And then again, they submitted it twice since then, but it just keeps getting denied as a duplicate.
[CUSTOMER][NEUTRAL] Right there.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] 1 2nd 1 2nd.
[AGENT][NEUTRAL] Yeah, you're fine.
[AGENT][POSITIVE] And she's really nice, so that's helpful.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Not that we don't treat everybody the day, but, you know, some of them are a little.
[CUSTOMER][NEUTRAL] Right
[AGENT][NEUTRAL] Are you to deal with.
[CUSTOMER][NEUTRAL] So 36,790.
[CUSTOMER][NEUTRAL] And da da da.
[CUSTOMER][NEUTRAL] One second, I'm sorry.
[AGENT][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] 37721. Let me look at the other one because I don't see where we would.
[CUSTOMER][NEUTRAL] I'm about to get my ducks in a row.
[AGENT][NEUTRAL] You're fine.
[CUSTOMER][NEUTRAL] OK, now I see it.
[CUSTOMER][NEUTRAL] OK, yeah. We, we need to request a refund. Do you want me to tell her or you're just gonna do a request?
[AGENT][NEUTRAL] It doesn't matter, just um.
[AGENT][NEUTRAL] Do you want me to just tell her that we'll process it with a request for the refund to be?
[AGENT][NEGATIVE] I mean, it doesn't, I'll do whatever.
[CUSTOMER][NEUTRAL] Yeah you can you can do a request and uh let me see if the same person processed the claim.
[CUSTOMER][NEUTRAL] Probably not.
[CUSTOMER][NEUTRAL] 356-7119
[CUSTOMER][NEUTRAL] Two different people, um, [PII] processed the first.
[CUSTOMER][NEUTRAL] So it would go, it would come to her, but you know what.
[AGENT][NEUTRAL] But we are assigned it, we don't assign it to anyone, so.
[CUSTOMER][NEUTRAL] OK, well, you know what, send her over and then I'll just send it to [PII] for [PII] to uh do it.
[AGENT][NEUTRAL] Oh,
[AGENT][NEUTRAL] Oh,
[AGENT][NEUTRAL] OK, so you do want me to transfer you?
[CUSTOMER][NEUTRAL] Yeah, go ahead and transfer so you don't have to do a her request and then somebody gotta figure it out.
[AGENT][NEUTRAL] Oh,
[AGENT][NEUTRAL] OK, well, OK.
[AGENT][POSITIVE] Well, all [PII], I can do that then. So, um, I appreciate you taking a look at this and helping me with this one or helping her. OK, [PII], well, have, I hope you do too. Thank you so much. All right. Bye-bye.
[CUSTOMER][POSITIVE] All righty.
[CUSTOMER][POSITIVE] No problem [PII], have a great rest of your day.
[CUSTOMER][NEUTRAL] All right, bye bye.