AccountId: 011433970860
ContactId: 34b50f9e-d0c8-42ae-875e-be04ee1e7efb
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 780080 ms
Total Talk Time (AGENT): 204673 ms
Total Talk Time (CUSTOMER): 243330 ms
Interruptions: 0
Overall Sentiment: AGENT=0.6, CUSTOMER=-0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/01/34b50f9e-d0c8-42ae-875e-be04ee1e7efb_20250501T16:31_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] in customer service. How are you?
[AGENT][POSITIVE] I'm good, memory. How are you?
[CUSTOMER][NEUTRAL] I'm good thank you um I have an insured on the line um she was initially calling to get help signing into the OSC. I have helped her with that and now she had a question regarding a claim that she filed.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] On, um, she used to be on her husband's policy now she has her own policy, but the claim's gonna be for her husband's policy because it was last year. I've got both policy numbers.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, what is the first one?
[CUSTOMER][NEUTRAL] Alright, her current policy is 259.
[CUSTOMER][NEUTRAL] 8904.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And her call back number is the number that's listed on that policy. I updated her phone number and her email address.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then the claim is gonna be on policy 147.
[CUSTOMER][NEUTRAL] 7436.
[AGENT][NEUTRAL] OK, and then do we by chance [PII] have the date of service or any of that?
[CUSTOMER][NEUTRAL] I do not, she just said it was last year.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK, no worries. I can check on it for her. Um, I've got everything I think I need, got her call back so you can transfer her over.
[CUSTOMER][POSITIVE] Alright thank you [PII] here she comes.
[AGENT][POSITIVE] All right, thank you.
[CUSTOMER][NEUTRAL] Mhm. Bye-bye.
[AGENT][NEUTRAL] This is [PII] in customer care. Am I speaking with [PII]?
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] Good morning. uh I understand that you needed to check on a claim, is that correct?
[CUSTOMER][NEUTRAL] Yes please it's from [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, [PII].
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] And I'm the patient, [PII].
[AGENT][NEUTRAL] OK, let me take a look.
[AGENT][NEUTRAL] And [PII], do you by chance have the claim number or the amount billed?
[CUSTOMER][NEUTRAL] Yeah, the amount
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Well, the total charges original on the primary claim was $476.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It's for Care now urgent care.
[AGENT][NEUTRAL] There's just a couple different claims that day, so.
[AGENT][NEUTRAL] Give me just a second to look.
[CUSTOMER][NEUTRAL] 5
[CUSTOMER][NEUTRAL] Pollen everywhere.
[CUSTOMER][NEUTRAL] We told that, that we need back.
[CUSTOMER][NEUTRAL] To
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So it looks like we did originally get a claim for that. um, it was denied just stating that we needed a date, excuse me, detailed explanation of benefits from the primary and then it looks like it was resubmitted and then uh a portion paid to the provider.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] For the residual amount, so.
[CUSTOMER][NEUTRAL] Can you tell me how much that was? Because I paid uh.
[CUSTOMER][NEGATIVE] I paid a payment to them so I'm thinking um that they owe that back to me.
[AGENT][NEUTRAL] So, total payment was $42.12.
[CUSTOMER][NEUTRAL] How much was uh was requested?
[AGENT][NEUTRAL] So the charge amount.
[AGENT][NEUTRAL] Came over. Let me add these other there's 3 different amounts on.
[AGENT][NEUTRAL] $87.12.
[AGENT][NEUTRAL] There is a charge for 2356, 1856 and 45.
[AGENT][NEUTRAL] Uh, the 45 is showing denied only because your primary provided full benefits, so there was nothing for us as a secondary.
[AGENT][NEUTRAL] And so the 2356 plus 1856 is where you get the $42.12.
[CUSTOMER][NEUTRAL] All right, so this is where it's kind of confusing.
[CUSTOMER][NEUTRAL] So, um,
[CUSTOMER][NEUTRAL] My policy is supposed to cover.
[CUSTOMER][NEUTRAL] Payment for urgent care.
[CUSTOMER][NEUTRAL] So I have um
[CUSTOMER][NEUTRAL] If I have urgent care, um, coverage for in uh outpatient services.
[CUSTOMER][NEUTRAL] My $60 payment that I made.
[CUSTOMER][NEUTRAL] Plus the $23.56 balance.
[CUSTOMER][NEGATIVE] Should have been paid directly, you know, to them and then they pay it back to me. $45 being denied because Primary paid for it, it didn't.
[CUSTOMER][NEUTRAL] Primary did not pay that $45.
[CUSTOMER][NEUTRAL] That's if that's a copay.
[AGENT][NEUTRAL] Let me see what was submitted on the claim.
[CUSTOMER][NEUTRAL] Because I
[AGENT][NEUTRAL] Um,
[CUSTOMER][POSITIVE] Thanks.
[CUSTOMER][NEUTRAL] You said there was a couple charges that same day. I just wanna make sure that.
[AGENT][NEGATIVE] They were just multiple claims it was it was submitted multiple times.
[CUSTOMER][NEUTRAL] Are we looking at just the.
[CUSTOMER][NEUTRAL] Because the one I I see is the 2356 balance owed.
[CUSTOMER][NEUTRAL] But again that was $476 for the charge. My primary insurance paid $6143.
[CUSTOMER][NEUTRAL] Um, there's an insurance adjustment of 33101.
[CUSTOMER][NEUTRAL] And then I paid 60 and it's that I owed 2356.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] The $1856 and the $45.
[CUSTOMER][NEGATIVE] Well, the $45 should have been reimbursed by y'all as well.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Yeah, could see on the explanation of benefits for the $45.
[AGENT][NEUTRAL] It shows 616 billed amount $45 and then it shows paid amount is the paid amount from the primary being $11.04 and then the adjustment of 3396 cents, so that's why it's showing that was paid in full.
[CUSTOMER][NEUTRAL] Well,
[CUSTOMER][NEGATIVE] It doesn't seem like that was submitted properly because I paid $60.
[CUSTOMER][NEUTRAL] Um, my
[AGENT][NEUTRAL] I mean it shows the amount paid $60 total charge for $76.
[CUSTOMER][NEUTRAL] Primary
[AGENT][NEUTRAL] And then down below.
[AGENT][NEUTRAL] On the explanation of benefits.
[AGENT][NEUTRAL] Yeah, cause then that's where.
[AGENT][NEUTRAL] I can send it over to somebody um to investigate if you think that you know it wasn't processed correctly in the claims department if you'd like me to [PII], and then have them call you back.
[AGENT][NEUTRAL] Um,
[AGENT][POSITIVE] On the excellent, like I said, on the explanation.
[CUSTOMER][NEUTRAL] Um, yes, please, cause I, I feel like.
[AGENT][POSITIVE] Uh, benefits, it, it does show.
[CUSTOMER][NEGATIVE] Because I feel like what should have been reimbursed was 8356.
[CUSTOMER][NEGATIVE] Should have been reimbursed because that was the kind of the balance after primary insurance paid.
[CUSTOMER][NEUTRAL] And I paid 60 of it. You all paid 2356. That was part of the 4212 you just said?
[CUSTOMER][NEUTRAL] But the 1856 and then denying the $45 it doesn't.
[CUSTOMER][NEGATIVE] 4212 is not, is not enough of a reimbursement to them. It should have been 8356, and I, I should be getting my $60 back.
[CUSTOMER][NEUTRAL] So yes, if you could resubmit that um claim for for um.
[CUSTOMER][NEUTRAL] Review
[AGENT][NEUTRAL] OK and then what's your callback number?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] So just to confirm, [PII], is that correct?
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] OK, um, so just give it 24 hours. I will send the request over now. Did you have anything else you needed me to check on today?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Uh yes, please, um.
[CUSTOMER][NEUTRAL] Well,
[CUSTOMER][NEUTRAL] Probably, uh, I, this is a.
[CUSTOMER][NEUTRAL] This has this does, I'm sorry, this one doesn't look like it's gone through primary insurance yet so let me, let me have them resubmit that to primary before I.
[AGENT][NEUTRAL] OK. All right.
[CUSTOMER][NEUTRAL] Uh, because you guys probably don't have a claim for it yet.
[AGENT][POSITIVE] Yeah, it's not a problem. Yeah, not a problem. We will give you a call back, [PII]. Have a good rest of your day.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you. You too. Bye-bye.
[AGENT][NEUTRAL] I'm