AccountId: 011433970860
ContactId: 3996fa72-947f-4ce7-93b9-61c1194c94be
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 614059 ms
Total Talk Time (AGENT): 167317 ms
Total Talk Time (CUSTOMER): 164943 ms
Interruptions: 2
Overall Sentiment: AGENT=0.4, CUSTOMER=-0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/23/3996fa72-947f-4ce7-93b9-61c1194c94be_20250123T14:25_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][POSITIVE] Good morning, [PII]. This is [PII] in customer service.
[AGENT][NEUTRAL] Hey [PII], how are you?
[CUSTOMER][POSITIVE] I'm doing good. Hey, I have Ms. [PII] calling from an um provider's office.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, with policy number.
[CUSTOMER][NEUTRAL] 21, 221.
[CUSTOMER][NEUTRAL] 652-2.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, she is checking on documents sent for pendent [PII].
[CUSTOMER][NEUTRAL] Uh, dependent for.
[CUSTOMER][NEUTRAL] I see he's dropped and notes say that his last day of coverage um was [PII].
[CUSTOMER][NEUTRAL] Um, she, I guess she's checking on the claim status for him.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, well, uh, you can send her through, and you said it was for part 4?
[CUSTOMER][NEUTRAL] Mhm. Yes.
[AGENT][POSITIVE] OK, you can send it through. You're welcome.
[CUSTOMER][POSITIVE] All right, thank you.
[AGENT][NEUTRAL] Hello Ms. [PII].
[CUSTOMER][NEUTRAL] I in [PII]
[AGENT][NEUTRAL] Hello Ms. [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Hi, this is [PII] with um the customer care team. How are you doing today?
[CUSTOMER][POSITIVE] I'm good, [PII]. How are you?
[AGENT][NEUTRAL] I'm doing good. So from what I got from the representative, um, you're checking on claim status, you wanted to see if some documents were received, is that right?
[CUSTOMER][NEUTRAL] Yes, I was told that um I needed to send a claim in an EOB for this patient for a certain date of service, so I want to see if you guys received it because I haven't heard nothing back.
[AGENT][NEUTRAL] OK, what's the date of service?
[CUSTOMER][NEUTRAL] The date of service is going to be [PII].
[AGENT][NEUTRAL] OK, and all the information provided is a verification of benefits, not a guarantee of payment. Hold on one moment, and it's for.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And this is for [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And what is the total bill amount?
[CUSTOMER][NEUTRAL] The total bill amount on the claim is for.
[CUSTOMER][NEUTRAL] Um, $120 even.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] And do you mind if I place you on just a brief hold while I look through these claims?
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, now what now?
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, hello [PII].
[CUSTOMER][NEUTRAL] Yes
[AGENT][POSITIVE] Thank you so much for holding. I apologize for that wait. So we received the claim several times, so I had to go through them to see what the original was. So the um original claim that we received, um,
[AGENT][NEUTRAL] We received it on
[AGENT][NEUTRAL] Sorry.
[CUSTOMER][NEUTRAL] Right, I, I know you received the original. Um, I spoke to someone back in October who told me the claim denied because it was requesting the primary explanation of benefits. Um, they told me to fax that.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII]. So back in December, actually I talked to them in December, I'm sorry, so I spoke to [PII] in December and she told me to fax it to that number. So I faxed the claim with the primary explanation of benefits to that number in December. So I'm trying to find out if you received it so you can process it.
[AGENT][NEUTRAL] So,
[AGENT][NEUTRAL] [PII] may have looked at the wrong claim, because like I said, there were several that were received for that data service. So going back to what I was trying to let you know, the original claim was denied because it showed that we received the explanation of benefits, but it showed that primary um provided full benefits.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So, we received 2.
[CUSTOMER][NEUTRAL] Let's see his primary leftover uh balance.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][POSITIVE] Yeah, they left a balance, which is why I sent the updated explanation of benefits.
[AGENT][NEUTRAL] OK. When did you send the updated because we, I'm trying to make sure I get these all together. So 611 was the last one we received [PII].
[CUSTOMER][NEUTRAL] I sent this in December.
[AGENT][NEUTRAL] OK, so that, so.
[AGENT][NEUTRAL] If, can I just go through the two that we have so that there's clarity because I'm jumping through and I just need to give you the information.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] So, the first claim that we received.
[AGENT][NEUTRAL] Um, was back in October and that claim was denied.
[AGENT][NEUTRAL] Um, hold on one second.
[AGENT][NEUTRAL] Saying that major medical paid the benefits and that if there was an explanation of benefits where there was a balance to send it in. So then we received it again on [PII] and that claim was denied saying that the insured's primary
[AGENT][NEUTRAL] Um, provided full benefits, so there are no benefits payable. That was the last claim that was processed.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEGATIVE] However, they did not for benefits. I said the explanation showing that they only
[CUSTOMER][NEGATIVE] Pay, they only pay $12.07 correct? The other $17.93 they denied is um.
[CUSTOMER][NEUTRAL] Let's see what did they put that as.
[CUSTOMER][NEGATIVE] On here it is service is not authorized by a network or primary care providers, so they denied that remaining 1793 is out of network and they didn't pay that or adjust it all.
[AGENT][NEUTRAL] Right, so as a second, if primary is not paying or denied, we cannot apply. So we for what they approve.
[CUSTOMER][NEUTRAL] OK, well, I'll be on the patient. Can I have a reference number?
[AGENT][NEUTRAL] There's no call reference number. You can use my name in today's date. The first initial to my last name is [PII]. You also, thanks for calling.
[CUSTOMER][POSITIVE] OK, have a great day. Thanks. Bye bye.