AccountId: 011433970860
ContactId: 3c4f3cf8-4bfc-4510-9370-e8a64b884e74
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1758359 ms
Total Talk Time (AGENT): 664012 ms
Total Talk Time (CUSTOMER): 487482 ms
Interruptions: 1
Overall Sentiment: AGENT=0.3, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/01/3c4f3cf8-4bfc-4510-9370-e8a64b884e74_20250401T15:34_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][NEUTRAL] Good morning, [PII]. My name is [PII], and I'm calling to check the status of a claim we haven't heard back yet since we submitted it in December.
[AGENT][NEUTRAL] Oh, OK. Well, I can definitely take a look into the claim for you. I'm sorry you haven't heard anything. Um, [PII], are you the insured or you're calling with the provider's office?
[CUSTOMER][NEUTRAL] Provider.
[AGENT][NEUTRAL] OK, and may I have the um members, well, may I have a good contact number in case we're disconnected and then the member's policy number?
[CUSTOMER][NEUTRAL] Sure, it's [PII].
[CUSTOMER][NEUTRAL] And the member's policy number is 01678723M as in Mary.
[AGENT][NEUTRAL] Thank you. And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] [PII], and date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service for the claim and the total bills?
[CUSTOMER][NEUTRAL] [PII] and the total bill amount is $885.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] $85. OK, here we go.
[AGENT][NEUTRAL] I believe I just located it. Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so we received the claim twice. Can you verify the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] It should be under Miami-Dade County Fire Department.
[AGENT][NEUTRAL] OK, here we go.
[AGENT][NEUTRAL] So we originally originally.
[AGENT][NEUTRAL] Hold on 1 2nd.
[AGENT][NEUTRAL] We originally received the claim on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Claim number is 3551431.
[AGENT][NEUTRAL] And on [PII], we denied the claim requesting the explanation of benefits from primary insurance.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Did, where did you send the request for more information?
[AGENT][NEUTRAL] Um, hold on, let me pull it, um, you'll be, hold on one second.
[AGENT][NEUTRAL] It's coming up now, hold on one moment.
[CUSTOMER][NEUTRAL] You're fine.
[AGENT][NEUTRAL] It was mailed to [PII].
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] That's the address.
[CUSTOMER][NEUTRAL] OK, um, what's a good way to get this to you really quickly because we, we haven't received that correspondence. The doctor's office is really bad about getting them faxed over to us. We're in a billing office that's separate from the doctor's office, so there's sometimes stuff lost in translation.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, um, so I can send you a copy of the explanation of benefits if you'd like, I can fax it to you, so you'll have that and then, um,
[AGENT][NEUTRAL] You can fax it, you can, however you like, you can send it through electronic, the payer ID or you can mail it.
[CUSTOMER][NEUTRAL] OK, um, I can send it with the fax and I can reference the claim number so that that EOB gets to the.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Gets applied to that claim, will that work?
[AGENT][NEUTRAL] Yes, that's totally fine. Um, let me see what the second, um,
[AGENT][NEUTRAL] Because there's a code here for the 2nd time that we received it. Let me make sure that's all that's needed. Hold on one second.
[CUSTOMER][NEUTRAL] You bet.
[AGENT][NEUTRAL] Because that was just the original and we received it again.
[AGENT][NEUTRAL] OK, wait a minute. So, for the second one that we received, um, that's claim number 3571573.
[AGENT][NEUTRAL] We received that claim um [PII], so the explanation of benefits has been received.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um, the claim was then denied because outpatient benefit for this calendar year has been met.
[CUSTOMER][NEUTRAL] Wait, [PII]?
[AGENT][NEGATIVE] [PII], we received it and [PII], it was denied.
[CUSTOMER][NEUTRAL] OK, and you said it was denied because it was processed as an outpatient service?
[AGENT][NEUTRAL] Mhm. It says outpatient benefit for the calendar year has been met. Is it supposed to be inpatient?
[CUSTOMER][NEUTRAL] Well, it's classified as emergency services. A 0427 is emergency transport of a patient.
[AGENT][NEUTRAL] Right, so that's outpatient. If they're not admitted into the hospital, then that's outpatient.
[CUSTOMER][NEUTRAL] OK, um, really quick, was it processed under the
[CUSTOMER][NEUTRAL] Uh, benefits for [PII] or [PII].
[AGENT][NEUTRAL] [PII] goes by the year of the data service.
[CUSTOMER][NEUTRAL] OK. So denied.
[CUSTOMER][NEUTRAL] After receiving.
[CUSTOMER][NEUTRAL] Copy.
[CUSTOMER][NEUTRAL] EOB and 4.
[CUSTOMER][NEUTRAL] Outpatient benefit.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] OK. So the full balance should go to the patient because
[CUSTOMER][NEUTRAL] Or can it? because is, is American Public Life classified as a Medicaid?
[AGENT][NEUTRAL] No, no, um, so this is a secondary insurance, but we don't determine patient responsibility because we're not primary, um.
[AGENT][NEUTRAL] So if there is an outstanding balance that would just be between provider and primary would um whatever the next steps would be billed or write off.
[CUSTOMER][NEUTRAL] I see.
[CUSTOMER][NEUTRAL] And if the primary applied to a deductible,
[CUSTOMER][NEUTRAL] It would probably go to the patient, yeah.
[AGENT][NEUTRAL] For the most part, y[PII].
[CUSTOMER][POSITIVE] Fair enough.
[CUSTOMER][NEUTRAL] All right, so for this one.
[CUSTOMER][NEUTRAL] Is there going to, I have 2 more accounts that I wanted to check on. Similarly, we had submitted claims and we just haven't heard back. Again, this might just be a case of having not receiving correspondence from the doctor's office, um, but am I gonna need a different reference number for each account that we check?
[AGENT][NEUTRAL] Um, um, it'll be the same for the entire call.
[AGENT][NEUTRAL] It'll be my name and today's date.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And how do you spell your name?
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] And then the first initial to my last name is [PII].
[CUSTOMER][POSITIVE] Thank
[CUSTOMER][NEUTRAL] And today's date which is [PII].
[AGENT][NEUTRAL] And did you need the, did you need both of the explanation of benefits for this member faxed over the original and the denial or just the last, the denial?
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] The second denial, the one ending in 573, if I can get that one for our records, that would help.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, hold on one second.
[AGENT][NEUTRAL] And then what's a good fax number for you?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And is that attention, [PII]?
[CUSTOMER][NEUTRAL] Actually if you could attention it um [PII] as [PII] Delta [PII] as in Mary, D [PII] in [PII] in [PII].
[AGENT][NEUTRAL] OK. Do I need to put attention all of, so for the ones that we're gonna go over, um, are you gonna need the explanation of benefits for them too?
[CUSTOMER][NEUTRAL] Possibly, and there are going to be uh a different attention.
[AGENT][NEUTRAL] It'll be, it'll be to the attention of each of the patient account numbers.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] Alright, so I just sent that um fax over for the first member.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Let me note this. And then what's the next member's policy number?
[CUSTOMER][NEUTRAL] It is.
[CUSTOMER][NEUTRAL] 02331177 M as in Mary L as in Larry 8
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] [PII], date of birth, [PII].
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And again just for the call, all the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service for this claim or this number, sorry.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And the total bill?
[CUSTOMER][NEUTRAL] Uh, let me check.
[AGENT][NEUTRAL] And you said this is for [PII], right?
[CUSTOMER][NEUTRAL] This is from what?
[AGENT][NEUTRAL] The member's name was [PII] Appointee.
[CUSTOMER][NEUTRAL] No. Uh, uh, first name was [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII] might be the subscriber if [PII] is a minor still.
[AGENT][NEUTRAL] Oh no, it's fine. I just need to know which one to look under. I have [PII] here.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then it was [PII]?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Looks
[CUSTOMER][NEUTRAL] [PII], yes.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, American Public Life is secondary after Blue Cross Blue Shield. They were billed, um.
[CUSTOMER][NEUTRAL] $900. I think the amount that was transferred over and billed to American public life is different. Let me see. Do you have one for $900?
[AGENT][NEUTRAL] No, not a total of 900. Um, what's the, what's the procedure code on the claim you're looking for?
[CUSTOMER][NEUTRAL] I do have uh one for 75654.
[AGENT][NEUTRAL] Well, I mean, so there's quite a few claims that came in on this date, um.
[CUSTOMER][NEUTRAL] Oh, let's see 80427.
[AGENT][NEUTRAL] Alright here we go, hold on one moment.
[AGENT][NEUTRAL] And did it also have 80425 on it as well?
[CUSTOMER][NEUTRAL] Yes, yes.
[AGENT][NEUTRAL] OK, here we go.
[AGENT][NEUTRAL] Alright, so that um claim was received on [PII].
[AGENT][NEUTRAL] Claim number is 356.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] 2364.
[AGENT][NEUTRAL] And on [PII], we paid out on the claim to the provider $250.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And did you need that check information?
[CUSTOMER][NEUTRAL] Uh yes, please.
[AGENT][NEUTRAL] OK, so it's check number 202-7185.
[AGENT][NEUTRAL] And
[CUSTOMER][NEUTRAL] Was there, uh, was this a bulk payment or?
[AGENT][NEUTRAL] So it was a single check, um, it was issued on [PII].
[AGENT][NEUTRAL] And it cleared on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. Um,
[CUSTOMER][NEUTRAL] So 250 was paid. What about the remaining balance? Was it uh adjusted off or applied to a patient copay, deductible, what?
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] Let me see what that was. Hold on one second.
[AGENT][NEUTRAL] So for 80425, the claim was denied because or that code was denied because the maximum benefit payable for the data service has been met. Uh, let me see what the benefit is. Hold on one moment.
[AGENT][NEUTRAL] So the benefit um for outpatient is up to $250 per calendar day and that was all applied to the other code on the claim.
[CUSTOMER][NEUTRAL] Uh, got it. OK, so that was the max amount that could be paid on an outpatient for one day.
[CUSTOMER][NEUTRAL] And the rest is patient responsibility.
[AGENT][NEUTRAL] Um, so we don't determine patient responsibility, so it'll be between primary and provider, um, to determine for the remaining balance.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right, that's it.
[CUSTOMER][NEUTRAL] Mm OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, next account, I guess.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] And did you need a copy of that explanation of benefits?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] And let me go to the faxes.
[AGENT][NEUTRAL] And then for this one, it'll be attention DMDFR 387-859.
[CUSTOMER][NEUTRAL] No, uh D M D F R 353009.
[AGENT][NEUTRAL] OK. That's not the patient account number on this claim. Should I put the one you have or the one that's on the claim?
[CUSTOMER][NEUTRAL] 01 that's on the claim.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] Alright, so we have DMDFR 387859.
[AGENT][NEUTRAL] For this claim.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, hold on one second.
[AGENT][NEUTRAL] So I'm getting ready to fax it over to you now. I'm just waiting for it to come up.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] All right, and the next member's policy number?
[CUSTOMER][NEUTRAL] It is.
[CUSTOMER][NEUTRAL] 016115
[CUSTOMER][NEUTRAL] 62 M as in Mary, L as in Larry 8.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] 25
[AGENT][NEUTRAL] Sorry, as soon as we finished, uh, getting the policy number, the fax popped up for me to send it one second.
[CUSTOMER][NEUTRAL] Oh, received the.
[CUSTOMER][NEUTRAL] It will be for herb
[AGENT][NEUTRAL] Alright, sounds
[CUSTOMER][NEUTRAL] That's come through.
[AGENT][NEUTRAL] So I'm sending the 2nd 1 now. It just popped up when you finished giving the other uh policy number, so you should be getting that one soon. Let me go back.
[AGENT][NEUTRAL] Alright, and can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Uh, I'm gonna butcher this, so I'm gonna spell it out.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Mercado, Mercado, Mercado, we'll go with that. Uh, [PII].
[AGENT][NEUTRAL] Thank you for that. And again, just for the call, the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service or the claim number for this claim?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And let's see, what was the.
[CUSTOMER][NEUTRAL] Well, UnitedHealthcare was billed initially for $885 but the crossover amount was different.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So we received the claim twice. Um, let me get that information for you.
[CUSTOMER][NEUTRAL] There's a procedure code 80427 and 80425 if that helps.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] and hold on one second.
[AGENT][NEUTRAL] OK, so the first claim we received was on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And that claim number is 353.
[AGENT][NEUTRAL] 261 9.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And on [PII],
[CUSTOMER][NEUTRAL] Oh wait, did that one deny because they needed the primary EOB?
[AGENT][NEUTRAL] Mhm, um, yeah, because it shows the one that we received showed that primary paid everything and then it's saying if they haven't, or
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me say that over again. So benefits are only payable if major provides. So if you all did submit um an explanation of benefits showing that they paid.
[AGENT][NEGATIVE] That may be the 2nd 1 here, but it was denied as a duplicate. So let me see what was received.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Because on [PII], we did send uh an appeal with the primary EOB.
[AGENT][NEUTRAL] Mhm. So that's probably what we received here on [PII]. Let me see. Hold on one second, January.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 7, not a second.
[CUSTOMER][NEUTRAL] UnitedHealthcare literally applied $24.40 to the coinsurance.
[AGENT][NEUTRAL] What?
[AGENT][NEUTRAL] So the 24/40 is what's being billed to us, the patient responsibility?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Wow.
[AGENT][NEUTRAL] OK. So for this one, there's two things that we can do. Either I can send this back to claims to be to be looked at and reprocessed if needed, because I mean, I do see a remittance here. I don't know if they're saying since this is not like the actual explanation of benefits because it has all the information here.
[AGENT][NEUTRAL] Um, so I can either send it back to have them look at this and reprocess or I can see if I can get someone on the line to speak with you now in reference to the claim, um, whichever you prefer.
[CUSTOMER][NEUTRAL] Um, if someone is available now, that's fine. If not, then just sending it back so that someone can review it. I mean, the remittance has all of the information that the primary EOB has. It's just classified under a different form and format. I'm just not sure what else you all need from us.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right, that's why I'm reaching out to claims because I see everything here. I don't know if there, if it has to be specifically on the EOB. I, I don't know, but that's what I'm gonna ask the claims examiner, um, and then I'm gonna transfer you to them so that they can assist you further with the claim in this remittance.
[CUSTOMER][POSITIVE] Thank you, [PII]. I appreciate it.
[AGENT][POSITIVE] You're very welcome. Before I do that, was there anything else I could assist you with today?
[CUSTOMER][POSITIVE] No, you've helped me out a whole bunch. Thank you so much.
[AGENT][POSITIVE] Well you're very welcome, [PII], and thanks for calling APL and hold on one moment while I get a representative for you, OK?
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How can I help you?
[AGENT][NEUTRAL] Hey, [PII], this is [PII] on the care team. How are you?
[CUSTOMER][POSITIVE] Doing well [PII] thank you how are you?
[AGENT][NEUTRAL] I'm doing good. Um, I have a provider on the other line. We were going through claim status and we have a remittance on file, but the denial code is asking for an EOB and she's like, well, everything's on there that's on the EOB, so she's trying to talk to somebody to get more information on why this can't be used and the patient responsibilities on there.
[CUSTOMER][NEUTRAL] Alright, let me take a look at what's the policy?
[AGENT][NEUTRAL] OK, um, it's 1611562.
[CUSTOMER][NEUTRAL] And who's the uh provider? What's her name?
[AGENT][NEUTRAL] Um, her name is [PII].
[CUSTOMER][NEUTRAL] And for
[CUSTOMER][NEUTRAL] Which member, the insured?
[AGENT][NEUTRAL] Uh, so it's part 4.
[CUSTOMER][NEUTRAL] Part 4, OK, for [PII] it looks like.
[AGENT][NEUTRAL] Oh, she was trying to, I didn't even look at it like that. She was trying to say it and I was like, I don't know. I just let her say it. She was like, I'm gonna butcher this. OK, yeah, you did it because I was I put that together.
[AGENT][NEUTRAL] Sorry.
[AGENT][NEUTRAL] She was trying.
[CUSTOMER][NEUTRAL] That's OK. That's OK.
[CUSTOMER][NEUTRAL] Yeah, got you, OK.
[AGENT][NEUTRAL] OK, so yes, and it's um which claim number? Hold on one second.
[CUSTOMER][NEUTRAL] And which claim number?
[AGENT][NEUTRAL] Let me get on base.
[AGENT][NEUTRAL] It is, hold on, I'm on, I was looking in on base.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Is it probably the 261 9?
[AGENT][NEUTRAL] Hold on, let me go back to [PII]. It's that last one there is data service [PII].
[CUSTOMER][NEUTRAL] Maybe.
[AGENT][NEGATIVE] Um, we received it twice. One was a dupe, but
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Hold on, let me get out of these notes. Oh my gosh, I was trying to uh.
[AGENT][NEUTRAL] Have the notes while I was on the call, but let me get back. Hold on one second.
[CUSTOMER][NEUTRAL] OK, I think I see it here because it looks like we were 32619. OK, that's what I thought alright, I'm just gonna pull that claim up.
[AGENT][POSITIVE] You got it.
[AGENT][NEUTRAL] Let me put that in my notes.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] 353-261-9 it looks like.
[AGENT][NEUTRAL] Mhm. And then the 0018 is the dupe.
[CUSTOMER][NEUTRAL] Yep, OK.
[CUSTOMER][NEUTRAL] Alrighty, um, and.
[CUSTOMER][NEUTRAL] It's gonna take a look at the EOB because what it's saying actually is.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] Do you um have a call back for her?
[AGENT][NEUTRAL] Uh-huh, so it is.
[CUSTOMER][NEUTRAL] Is that the number listed?
[AGENT][NEUTRAL] [PII], I'm sorry, [PII].
[CUSTOMER][NEUTRAL] OK, and um the patient was verified, right?
[AGENT][NEUTRAL] Yes, well, this is the provider, but yes, she's verified.
[CUSTOMER][NEUTRAL] Yeah, yeah, OK, patient information. OK, alright, if you wanna go ahead and pass her through, um, [PII], I'll try to take it from here. I'm gonna pull up the mail and just see exactly what I'm looking at, OK?
[AGENT][POSITIVE] All right. Thank you.
[AGENT][NEUTRAL] I already
[AGENT][NEUTRAL] Alrighty hold on one moment.
[AGENT][NEUTRAL] Hello, [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Thanks so much for holding. I have [PII] on the line and she'll be assisting you further, OK?
[CUSTOMER][POSITIVE] Thank you so much, [PII].
[AGENT][POSITIVE] You're welcome. Thanks for calling APL. Bye-bye.
[CUSTOMER][POSITIVE] Thanks.
[CUSTOMER][NEUTRAL] Hello [PII].