AccountId: 011433970860
ContactId: 611583a8-78e3-4835-b4a7-3f049af5d3e5
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 661229 ms
Total Talk Time (AGENT): 258293 ms
Total Talk Time (CUSTOMER): 340780 ms
Interruptions: 7
Overall Sentiment: AGENT=0.3, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/21/611583a8-78e3-4835-b4a7-3f049af5d3e5_20250121T13:44_UTC.wav
--------------------------------------------
[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII]. I'm calling from a provider's office, um, regarding a claim, um, that we received back from your um.
[CUSTOMER][NEUTRAL] From your company.
[AGENT][NEUTRAL] OK, when, OK, so are you needing claim status, [PII]?
[CUSTOMER][NEUTRAL] Yes, yes.
[AGENT][POSITIVE] OK, yes ma'am, I can help you with that. And [PII], what is a good callback number for you please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yes, [PII].
[AGENT][NEUTRAL] Thank you. And the member's policy number, please?
[CUSTOMER][NEUTRAL] 02521706.
[AGENT][POSITIVE] Thank you. One moment.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And any information [PII] that I do provide for you today would be a verification of benefits and not a guarantee of payment. What is your patient's name and their date of birth?
[CUSTOMER][NEUTRAL] [PII], [PII].
[AGENT][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] Mhm. You're welcome.
[CUSTOMER][NEUTRAL] And we did receive an EOB with a payment on it and um I'm not understanding how and why so it's really clarification.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] And what is
[AGENT][NEUTRAL] OK, what is the data service and total bill amount for this claim?
[CUSTOMER][NEUTRAL] OK, so, um, the date is [PII], um, he has Blue Cross Blue Shield as primary, so we billed $268.74 after Blue Cross Blue Shield processed this primary, they did submit um $28.77 to the um secondary.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and do you have the claim number?
[CUSTOMER][NEUTRAL] Uh, yes, for your claim number, yes, I do. I think I put it in because I went to your portal as well for uh answer to my question and I couldn't, so I do have the claim number and all.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Is my um.
[AGENT][NEUTRAL] And what is that?
[CUSTOMER][NEUTRAL] 3507536
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so yes, ma'am, I do see that claim.
[AGENT][NEUTRAL] Uh, one moment while I pull up the information on it.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so I see there was a benefit paid in the amount of $1.60.
[AGENT][NEUTRAL] On code 81001.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] And then the office visit charge that was denied.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] That was denied because office visits are not covered by this policy.
[CUSTOMER][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Uh.
[AGENT][NEUTRAL] The supplemental policy doesn't cover office visits.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK, I'll make a note of that so that we know um that for the future. OK, OK well that answered the question.
[AGENT][NEUTRAL] That some do, but this particular one, his employer does not.
[AGENT][NEUTRAL] Does not cover office visits.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] OK perfect then that makes sense so then he that charge will go down to his responsibility, um, OK.
[AGENT][NEUTRAL] And we don't determine patient responsibility. [PII], that would be up to the provider to determine that since we're not a major medical insurance.
[CUSTOMER][NEUTRAL] OK, OK, not a problem, not a problem, yeah, because it was already processed um by their uh primary insurance I guess they have Blue Cross Blue Shield and then this is a supplement plan.
[CUSTOMER][POSITIVE] OK. So thank you so much. I think he was the only one with this insurance that I have today, Ms. [PII], um.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. And you, and you said you already have our portal, correct?
[CUSTOMER][NEUTRAL] Well, go ahead.
[CUSTOMER][NEUTRAL] Yes, I did sign up for your portal so I, I can go there but it doesn't tell you all of that like it didn't, it didn't give the explanation on the EOB or on the portal.
[AGENT][POSITIVE] OK, good.
[AGENT][NEGATIVE] On the all EOBs, well, on all EOBs there should be 2 pages.
[CUSTOMER][NEGATIVE] It didn't get me.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] And the remark codes will always be on the 2nd page.
[CUSTOMER][NEUTRAL] You know what, OK, so I did go down, right? And you go to the 2nd page.
[CUSTOMER][NEUTRAL] Uh well, you know what the this EOB, it looks like a.
[CUSTOMER][NEUTRAL] Like a little spreadsheet, right? And then below it it has um like deductible meds, certificate, all this other stuff. The second page is a.
[CUSTOMER][NEGATIVE] It didn't have any, uh, it, it just has, uh, this portion is non-negotiable all over it, the stamp, the watermark, and there's no remark code on this second page.
[CUSTOMER][NEUTRAL] So it didn't say that now under the the the spreadsheet or the little um yeah the Excel sheet on the first page it says this product does not have a provider participation network. I didn't know what that meant or if that because that's kind of on the same line as total benefits paid so I wasn't sure if that was, you know, but the second page didn't have.
[AGENT][NEUTRAL] Let me just look at this COB cause I don't.
[AGENT][NEUTRAL] I don't, I'm not.
[AGENT][NEUTRAL] familiar with a lot of what you're saying. So let me just look at it.
[AGENT][NEUTRAL] So it should say APL.
[CUSTOMER][POSITIVE] And, and you're right because it does.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] On the upper left corner to the right side, it should say explanation of benefits. This is not a bill. OK, come down. There should be two line items.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And next to the first line item where it says 99213, there should be a 1 in the remarks.
[CUSTOMER][NEUTRAL] It is a one. Uh-huh.
[AGENT][NEUTRAL] OK. Alright, and then it shows $1.60.
[AGENT][NEUTRAL] Um, for that second line item is paid.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK. And OK, deductible mat. OK, that's at the bottom of the page and certificate, not applicable, inpatient, OK. And then,
[CUSTOMER][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] It's still loading. It takes a moment to get to that, to get the 2nd page. Uh-huh, but I can see that on the 2nd page it has APL explanation benefits on the for and then it has remark, it has a number 1.
[CUSTOMER][NEUTRAL] 2nd page.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] B2E001 office visits are not covered by this policy.
[CUSTOMER][NEUTRAL] Ours does not have that for some reason now do you see because ours just have this water mark all over it that says this portion is nonnegotiable and then when I go into the remark section it's blank. I mean that's all we see is that water mark this portion is nonnegotiable so it's not showing up on.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] What we have, but then it does say at the bottom if, if you disagree, I had that little disclosure underneath it, but there's nothing in there. But typically that's where it would be on this page.
[AGENT][NEUTRAL] Correct. It would be, uh-huh, it should be on page 2.
[CUSTOMER][NEUTRAL] Mhm, cause we only have the two.
[AGENT][NEUTRAL] And the bottom there, very thing should say if you disagree with decisions made, you have the right to an appeal.
[CUSTOMER][NEUTRAL] It does say that under the little chart. It does say that, but when you look inside the chart, it has the remark and then the remark description and nothing is there on this one.
[AGENT][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] And did I pull this one off the website? Let me see if I can pull it up on your website if it comes up different.
[AGENT][NEUTRAL] Uh, that one.
[AGENT][NEUTRAL] I don't know because the, the watermark that you're talking about, I, I'm not sure about that.
[CUSTOMER][NEUTRAL] So see, maybe I don't know because that that that watermark is 100% like covering this whole page and I'm like, you know, and so maybe that's it.
[AGENT][NEUTRAL] Uh, honestly.
[AGENT][NEUTRAL] Um, that doesn't.
[AGENT][NEUTRAL] Yeah, mine, I mean, I'm, I'm actually looking at that EOB and that's not.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEGATIVE] At all what I see.
[CUSTOMER][NEUTRAL] Got you, got you. Well, you know what I'm trying to pull it up from because this is what we received, um, I don't know if we received a paper copy or something. I don't know.
[AGENT][NEUTRAL] I was gonna say.
[AGENT][POSITIVE] Yeah, try it, try it again.
[AGENT][NEUTRAL] If you're logged into the portal.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I'm trying to load it upload it.
[AGENT][NEUTRAL] And
[CUSTOMER][NEUTRAL] Download it.
[AGENT][NEUTRAL] Let me look at this, hold on one second, let me.
[CUSTOMER][NEUTRAL] Alright, let's see.
[CUSTOMER][NEUTRAL] Uh, so yes, when I download it from your portal you're right, and you all don't see that watermark, but yeah, so now I see it 1-D2E0001. OK, so it may be best because what we received in the mail or however we if this was a remittance electronic remittance, then it came through completely different that second page did at least. Mhm.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Uh,
[AGENT][NEUTRAL] OK. OK. So, but you do see that remark code now that I was, OK.
[CUSTOMER][NEUTRAL] But I see it is there.
[CUSTOMER][NEUTRAL] Yes, I, mhm.
[AGENT][POSITIVE] Well, perfect. OK. Well, you are you are so welcome. You are so welcome. So is there anything else?
[CUSTOMER][POSITIVE] Thank you so much for your patience.
[CUSTOMER][NEUTRAL] Is there a reference number?
[AGENT][NEUTRAL] Um, you would use my name along with today's date.
[CUSTOMER][POSITIVE] OK, then so, OK, well, that's good, good enough, good enough, but that was all, Miss [PII]. Thank you for your help today.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Well, you are certainly welcome and I hope that you have a wonderful day, [PII]. Thank you again for calling APL.
[CUSTOMER][POSITIVE] Thank you you as well.
[AGENT][POSITIVE] Yes, ma'am. Thank you. Bye-bye.
[CUSTOMER][NEUTRAL] Bye bye.
[CUSTOMER][POSITIVE] You're welcome bye bye.