AccountId: 011433970860
ContactId: 5a440cc5-d43f-4a59-9f7f-74bf54bf23b8
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 501290 ms
Total Talk Time (AGENT): 214609 ms
Total Talk Time (CUSTOMER): 272144 ms
Interruptions: 10
Overall Sentiment: AGENT=1, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/19/5a440cc5-d43f-4a59-9f7f-74bf54bf23b8_20250619T14:03_UTC.wav
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[CUSTOMER][NEUTRAL] We specialize in
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yes, hi, good morning, this is [PII]. I'm calling regarding one of my members whose son's claim was denied by APL.
[CUSTOMER][NEUTRAL] So I'm calling to find out um the the reason.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Sure, I can get clarification regarding that claim. Uh, [PII], can I get a good call back number from you first in case we're disconnected?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Sure, it's [PII].
[AGENT][NEUTRAL] OK, thank you. And then do you have that policy number?
[CUSTOMER][NEUTRAL] The policy number is 02583472.
[CUSTOMER][NEUTRAL] What.
[AGENT][NEUTRAL] OK, and then, uh, what was the name and date of birth for the member please?
[CUSTOMER][NEUTRAL] The member who's um claim is [PII] and his date of birth is [PII].
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Perfect thank you so much for verifying that. Do you have that claim number by chance?
[CUSTOMER][NEUTRAL] OK, this is what the hospital told me the claim number was 346-7999.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, one moment please.
[AGENT][NEUTRAL] Oh this is a older claim, OK.
[CUSTOMER][NEUTRAL] From 2024, yeah.
[AGENT][NEUTRAL] Yes, I see. OK. Give me just a moment.
[AGENT][NEUTRAL] OK, so according to what I have here for this particular claim, it does state, of course that as this is a secondary medical policy, um, their major medical would have had to have contributed something to this um treatment, OK.
[CUSTOMER][NEUTRAL] They did it's subject it was subject it was subject to deductible, so.
[AGENT][NEUTRAL] Right, OK, so then it looks like we're missing that information, that explanation of benefits showing that information.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEGATIVE] So what exact because they, I spoke to the hospital and they will not.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] How do I say it, they will not resubmit the claim, so how do we get this claim processed because I spoke with United and all the claims for Lucas were covered.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, for January, February, March, and
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] As a matter of fact, they are getting ready the hospital to submit the claims for [PII], I'm sorry, for [PII] because this one was February.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Yeah, why would the reason for the decline be another payer?
[CUSTOMER][NEGATIVE] I don't understand that.
[AGENT][NEUTRAL] Well, this policy is, well, this policy is it's secondary medical, it's very dependent on major medical. If major medical does not contribute anything, then this policy can't pay anything. So we do need that explanation of benefits from the primary medical showing that information. So according to this claim, we did not receive that.
[CUSTOMER][NEUTRAL] No, that
[CUSTOMER][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] And usually, so.
[CUSTOMER][NEGATIVE] I, I guess I just wanna be clear so I don't want to keep running in circles because I'm gonna be honest, I called you guys last week and they told me there were no claims for Lucas for [PII] and that's what I told my client.
[AGENT][NEUTRAL] Sure.
[AGENT][POSITIVE] No worries.
[AGENT][NEUTRAL] OK, so I will say this is the confusion because I did find that when you give me the claim number this is for a different policy. The policy number you gave me was one that was active from [PII]. Uh, this is an older policy number.
[CUSTOMER][NEUTRAL] Right, because the old one doesn't, yeah, the old one doesn't pull up in the.
[AGENT][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] In the online system I can only pull this.
[AGENT][NEUTRAL] Oh, on the right, yeah, that makes sense. um, OK, so if you'll give me just a moment, I'm actually going to, I'm sorry, go ahead.
[CUSTOMER][NEUTRAL] Yeah, it doesn't be.
[CUSTOMER][NEUTRAL] No, yeah, so that with a new portal it doesn't let me pull up the old ID card.
[AGENT][NEUTRAL] No, that's perfectly fine. I can give you that. I can give you that older policy number if you need that just for your records so you know which claim this is associated with. Sure, let me know when you're ready I'll give you that.
[CUSTOMER][NEUTRAL] Right before the old portal, yeah.
[CUSTOMER][POSITIVE] Yeah, just so next time I I get the correct, correct.
[CUSTOMER][POSITIVE] I'm ready, yep.
[AGENT][NEUTRAL] OK, so that is 02.
[AGENT][NEUTRAL] 45.
[CUSTOMER][NEUTRAL] Like.
[AGENT][NEUTRAL] 55.
[AGENT][NEUTRAL] 68.
[CUSTOMER][NEUTRAL] 02455568
[AGENT][NEUTRAL] Correct, OK, so at this point, um, if what you're stating the provider isn't willing to do anything with it at this point, um, again, all we need is that primary EOB stating what was contributed again to either co-pay deductible or co-insurance so you can send that to us the member can send that to us, uh, whatever is easier for y'all, um, I do have, let's see, um, mailing address I can give you a fax number.
[AGENT][NEUTRAL] What would you prefer?
[CUSTOMER][NEUTRAL] No, no, if he gives it to me, can I just put it, drop it in the portal like submit a claim?
[AGENT][NEUTRAL] You should be able to.
[CUSTOMER][NEUTRAL] Yeah, OK, so here's my other, I guess my other question is, is that typically when they.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The hospital like now they're gonna submit the claims for Lucas because they noticed they didn't submit claims for.
[AGENT][NEUTRAL] Oh,
[CUSTOMER][NEUTRAL] Um, for March, for [PII], so they're gonna submit them today, today or tomorrow, and I told him let me call APL and see why they denied this one. So typically when they submit the claim to you.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] How do you pay?
[CUSTOMER][NEUTRAL] They submit the EOB with it, is that what you're telling me they submit the United EOB?
[AGENT][NEUTRAL] They're supposed to. That's the that's the information we need, yes, so for again this kind of policy we have to have essentially just the itemized statement for whatever procedure treatment that was received, uh, that shows any diagnosis or procedure codes and then we would need that primary EOB.
[CUSTOMER][NEUTRAL] I, I guess that's what I'm trying to understand.
[CUSTOMER][NEUTRAL] So it's up to.
[CUSTOMER][NEUTRAL] The I guess the in this case it's um I think memorial um [PII] Children's for his therapies so typically when they submit the claim they need to submit the UB40 which is what they told me they submitted and then on top of that they have to submit the EOB from United.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Yes, yes, yes.
[AGENT][NEUTRAL] The primary EOB. Yes, absolutely. Since this is a secondary medical, it's very dependent on that.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, so now I gotta try to figure out how to get that OK.
[CUSTOMER][NEUTRAL] I don't know if the hospital is gonna do it or not. I don't know. I mean.
[AGENT][NEUTRAL] They should have it. I mean, you know, if, if they did file with the major medical they should have that information.
[CUSTOMER][NEUTRAL] No, no, yeah they do they do they did file because they did tell me it was subject to deductible and that's where the balance is coming from and.
[AGENT][NEUTRAL] Right, and that's what again this policy is designed to help with so we just need that showing that information.
[CUSTOMER][NEUTRAL] Right, OK, so we're missing the EOB. OK, alrighty, and the claim number is correct so I can put it on the EOB and put for policy number 02455568, claim number 3467999 and then you guys would process, OK.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] That's correct.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] Alrighty, um, OK, I guess I will try calling the hospital again. Oh my [PII], OK, thank you.
[AGENT][POSITIVE] Alright, I'm so sorry for the confusion. I know that's quite a bit. Did you have any other questions for me?
[CUSTOMER][NEUTRAL] No, that's OK.
[CUSTOMER][POSITIVE] No, that's it for today. Thank you.
[AGENT][POSITIVE] All right, you are very welcome. I hope you have a great rest of your day.
[CUSTOMER][POSITIVE] You too take care bye bye.
[AGENT][POSITIVE] Thanks. Bye bye.