AccountId: 011433970860
ContactId: 3f262b23-984f-4775-b245-88a5367da036
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 511559 ms
Total Talk Time (AGENT): 248546 ms
Total Talk Time (CUSTOMER): 216535 ms
Interruptions: 2
Overall Sentiment: AGENT=0.1, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/11/3f262b23-984f-4775-b245-88a5367da036_20250411T12:10_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII]. I have a question regarding, I just got a notification for a claim that was submitted, um.
[CUSTOMER][NEUTRAL] I guess it was approved on the [PII], but I just got the notification.
[AGENT][NEUTRAL] Are you the policy holder?
[CUSTOMER][NEUTRAL] But um the amount.
[CUSTOMER][NEUTRAL] I am.
[AGENT][NEUTRAL] And what's your policy number?
[CUSTOMER][NEUTRAL] I don't have that. Can I give you in some other information? Uh, let me look on here.
[AGENT][NEUTRAL] I can search by your social.
[CUSTOMER][NEUTRAL] OK, that's fine. [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] That's your social security number?
[CUSTOMER][NEUTRAL] Yes it is [PII].
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, you were cutting in and out then.
[AGENT][NEUTRAL] Give me 1 2nd. It's OK.
[CUSTOMER][POSITIVE] Oh, OK, sorry about that.
[AGENT][NEUTRAL] And what type of policy do you have?
[CUSTOMER][NEUTRAL] Medical.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Supplement.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And if you could verify your date of birth, your mailing address, and an email address, [PII]?
[CUSTOMER][NEUTRAL] Um, date of birth [PII] mailing address [PII]. Email address [PII].
[AGENT][NEUTRAL] And
[AGENT][POSITIVE] OK, thank you. What's a good call back number in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And you said that you received correspondence regarding a claim?
[CUSTOMER][NEUTRAL] Right, that it was processed.
[CUSTOMER][NEUTRAL] And I can see it online.
[AGENT][NEUTRAL] And your
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] But the amount that was issued to that particular company was too much. I don't know what they submitted because I originally sent my documentation, but it needed a diagnostic code, so I am trying to notify you all that it was too much paid because I paid part of that amount, and I was contacting the doctor's office so they can return that money to you all so that can be credited back to my account.
[AGENT][NEUTRAL] And so
[CUSTOMER][NEUTRAL] Um, because I'm looking at 608, I'm sorry.
[AGENT][NEUTRAL] I was gonna so so in a situation like this, um, because the provider submitted the claim if you paid something to what's the name of the uh.
[AGENT][NEUTRAL] Facility or the practice.
[CUSTOMER][NEUTRAL] For the bone and joints.
[AGENT][NEUTRAL] OK, so you, if you paid something out of pocket to uh Georgia bone and joint, um.
[AGENT][NEGATIVE] Then they owe you a refund.
[AGENT][NEUTRAL] Because the amount that we pay is what's reflected on your primary insurance EOB, so it is correct.
[AGENT][POSITIVE] The payment sent to them is correct.
[AGENT][NEUTRAL] And so if you've paid out of pocket, it perhaps could mean that your policy is overpaid and then they would need to reimburse you.
[AGENT][NEGATIVE] We wouldn't request a refund from them.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] But I, I, yeah, I, I guess I'm just having a hard time understanding why she would submit that because she knew it was only half of that that was due. So that, and I, and I told her, um, yeah, I understand the EOB and it reflected, but yeah, it, it should have reflected what was due, which was 308, not 608.
[AGENT][NEUTRAL] And unfortunately, [PII], yeah, that's not how it works. When they attach a copy of your, your primary ELB we have to abide by that and even if they said, you know, and they usually don't say what the patient paid out of pocket, but even if they did, uh, we still have to go by what's on the primary ELB.
[CUSTOMER][NEUTRAL] So yeah.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then you'll have to settle up the situation with them so then they would owe you a refund. How much did you pay out of pocket?
[CUSTOMER][NEUTRAL] 300
[AGENT][NEUTRAL] OK. So we paid them 608-77, which, um, did you receive a copy of your major medical explanation of benefits?
[CUSTOMER][NEUTRAL] I did and it and it reflected that I owe 308 so that's the portion, the portion that I submitted to you all, but when I did it, it wasn't um processed because I needed more a diagnostic code.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And so when I called the doctor's office, yeah, I told her that. She's like, OK, I can do it on your behalf. I was like, OK, you know.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, on the EOB it actually shows that your responsibility was 608-77.
[AGENT][NEUTRAL] And so you would just, you know, so that total subtracted from what you paid is perhaps what they may owe you. So you'll need to reach out to bone and Joint.
[CUSTOMER][NEUTRAL] So a a quick question. So this policy is it a is it, is it 1500 or 1000?
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Um, let me see, I'll take a look at that for you. So this is an outpatient benefit and that benefit amount is, uh, it's up to, so your inpatient and your outpatient benefit is combined, uh, for a maximum of up to $1500 per calendar year.
[CUSTOMER][NEUTRAL] This supplement.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] And I only use this for, you know, minor, not taking away from it unnecessarily when I did that. So that's why I'm not, I'm not happy right now because, you know, other things can come up that I may need it for and this was one of those times where it was over, uh, yeah.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK, OK, I will, um.
[AGENT][NEUTRAL] Yeah, so, so because this policy, the policy you have with APL, we assist with any amounts applied towards your deductible, uh, which is the 60877. So if you pay them $300 and something, there should be a credit on your account.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And they should refund that that that amount to you, but you'll need to contact them though to discuss it.
[CUSTOMER][NEGATIVE] And it's no way that I could give that money back to put on this account.
[AGENT][NEUTRAL] What you, what you paid out of pocket?
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] No.
[AGENT][NEGATIVE] Unfortunately, when they send a claim in with any insurance company, this one or your major medical, it doesn't work like that.
[CUSTOMER][POSITIVE] Understandable.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK. Um.
[CUSTOMER][POSITIVE] Thank you so very much. I will contact them to see.
[CUSTOMER][NEUTRAL] Um, about the, the refund that's due to me, OK.
[AGENT][NEUTRAL] Uh huh, and, and we just processed the claim on yesterday, so they may not have received the check yet, but if you're online and you see a copy of the explanation of benefits, the APL ELB, you can actually use that and let them know that you're looking at the ELB from APL and it shows where we issued a check for 608-77.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] You know, and you paid however much you paid out of pocket, uh, is my account overpaid?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then if so, you know, can I get a refund?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So are you able to see the explanation of benefits online?
[CUSTOMER][NEUTRAL] I will, and I'm looking online and I'll look at it.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] One second. Actually I can. That's how I knew you all paid. I was like, wait a second. That was too much. So right.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Yeah, so you can actually use that document because they may not have received the check yet.
[AGENT][NEUTRAL] And maybe show them the document or email it to them or however you choose to do it to show that a payment is coming their way for 608-77 and generally most doctor's office, they have to, you know, they, they have to reconcile their accounts um and they'll have to refund you any over overpaid amount.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And they have to
[CUSTOMER][POSITIVE] Got you OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Well they open at [PII] here in [PII], so what I'll do, I, I will give them a call and I'll let them know because I do see it here online because that's how I immediately set up and I was like, wait a second, that's not accurate. I now I understand, yeah, what happened, so.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Right, right.
[CUSTOMER][POSITIVE] OK, alright, well thank you so very much for your explanation and your time and I hope you have a great rest of your day.
[AGENT][POSITIVE] All right, [PII], if no other questions, thanks for calling APL. Have a good day.
[CUSTOMER][POSITIVE] You too thank you bye bye.
[AGENT][NEUTRAL] Uh bye-bye.
[CUSTOMER][NEUTRAL] I