AccountId: 011433970860
ContactId: 62f32852-8f75-4492-95a4-bb0d29cf4d4f
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 736559 ms
Total Talk Time (AGENT): 424911 ms
Total Talk Time (CUSTOMER): 197992 ms
Interruptions: 3
Overall Sentiment: AGENT=0.2, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/28/62f32852-8f75-4492-95a4-bb0d29cf4d4f_20250228T14:23_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. With whom am I speaking and how may I help you?
[CUSTOMER][NEUTRAL] Hi, good morning. My name is [PII]. I'm calling you from the provider office, Specialty care surgical Assist LLC and I'm looking for a claims information for a patient today.
[AGENT][NEUTRAL] OK, so I can assist you with the claim status. What is the members uh.
[AGENT][NEUTRAL] ID number policy number.
[CUSTOMER][NEUTRAL] Sure. The policy ID I have here, 1954796.
[AGENT][NEUTRAL] And what is a good call back number for you in case we get disconnected?
[CUSTOMER][NEUTRAL] Uh-huh. The callback number is area code [PII], and it's a direct line.
[AGENT][NEUTRAL] Thank you for that information. One moment please while I get that pulled up and then I'm gonna have you verify some information. Thank you.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] Verify the member's name and date of birth.
[CUSTOMER][NEUTRAL] Patient name, it's uh
[CUSTOMER][NEUTRAL] [PII]. Date of birth of.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you and what's the data service and charge amount you're looking for today?
[CUSTOMER][NEUTRAL] This is for [PII].
[CUSTOMER][NEUTRAL] Bill charges of $745 even.
[AGENT][NEUTRAL] Thank you for that information and verification of coverage does not guarantee the payment of a claim. One moment while I check to see if I can locate a claim for that data service.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][POSITIVE] Thank you for your patience. One moment.
[CUSTOMER][POSITIVE] You're welcome uh huh.
[AGENT][NEUTRAL] Alright, so I'm looking at that claim, that claim number is 3490058. Give me one moment to get the rest of the details.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I'm sorry, let me give you a different, that was the first claim that was submitted that was that claim number and we denied it.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Because we didn't have the correct primary EOB.
[AGENT][NEUTRAL] But I have the most recent claim number as 353.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 7106.
[AGENT][NEUTRAL] And this claim denied, let me see when it denied.
[AGENT][NEUTRAL] It was received on [PII]. It was denied on [PII], and the reason for denial is that we do not make a payment on a claim where the uh primary EOB is showing there is no patients responsibility, OK?
[AGENT][NEUTRAL] So if you have an EOB that shows that the member has a responsibility only in the form of a co-pay, a co-insurance or deductible, you can submit that, but what you submitted does not show that.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEGATIVE] We don't have a timely filing limit.
[CUSTOMER][NEUTRAL] And then
[AGENT][NEUTRAL] Mhm, go ahead.
[CUSTOMER][NEUTRAL] On January, on [PII].
[CUSTOMER][NEGATIVE] Um, I made a call on this, uh, denial, and I think you are the one who answered my phone and
[CUSTOMER][NEUTRAL] Um, you say that you found that payment, I mean the EUB where the patient responsibility is um mentioned because we have already submitted the correct EOB.
[CUSTOMER][NEUTRAL] Where there is serving the patient responsibility as a deductible.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So you send the claim back for reprocessing. Uh-huh.
[AGENT][NEUTRAL] I do see that. So hold on, I do see that. I do see that and uh hold on, let me read my notes because I do see I spoke to you and I did send an email for that examiner to reprocess that claim. Uh, let's see provider [PII] doesn't understand why claim originally paid under 3,511,000 after being voided, so we had to void the claim for some reason, and when she reissued it, let's see.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] OK, so the processor says she can't reached out to you, OK? Um, she's saying she advised you that, let's see, wait a minute, I don't know if she spoke to you. She said contacted [PII] and [PII] at [PII]. The original claim 31,100 was paid in error, right? So it shouldn't have been paid. That's what she contacted you all and told you.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, the major medical EOB, which is the primary LB shows a deductible, but also that the claim was denied by the major medical.
[AGENT][NEUTRAL] OK. Restart authorization was not provided. That's why the primary insurance denied it. She says she conveyed this information to [PII] at the time the claim was processed and not paid. She said she left a message for both of you all and will submit copies of the major medical ELBs which will show the bill served is not covered by the health health plan. So that's why it was not reprocessed, OK?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] yeah.
[CUSTOMER][NEUTRAL] OK, so, um.
[AGENT][NEGATIVE] It never should have been paid in the first place, OK? That's what she's saying because the, the primary EOB did not show a patient's responsibility in the form of a co-pay or co-insurance or deductible, so you all were paid in error, so the claim was voided and it's been reprocessed, but it's not gonna receive a payment that's why it was denied citing what I said when we first started speaking that please submit the EOB that shows a patient's responsibility.
[CUSTOMER][NEUTRAL] You know medical call.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] So you would need to reach out to the primary insurance company because originally they denied it saying you didn't get authorization for pre-cert, OK? So any time there's no authorization obtained, if they deny the claim we're gonna deny the claim. We're only gonna consider the claim if there's a co-pay co-insurance or deductible and in you all's case you have not provided us with the burden of the proof in the form of a primary LLB that shows that information, OK?
[CUSTOMER][NEUTRAL] OK, the first initial claim, the primary insurance was denied.
[CUSTOMER][NEUTRAL] I don't see it was denied for an authorization, but.
[CUSTOMER][NEUTRAL] Uh, let me check.
[CUSTOMER][NEGATIVE] Yeah, it doesn't show any uh denied for an authorization. It was denied for uh missing information.
[AGENT][NEGATIVE] Well, even, even so, even so, it was denied, OK, [PII]? We, we don't pay denied claims, OK? So whether it was denied for off or whether it was denied for missing information to obtain an oath, whatever the case was, it was denied. We do not pay denied claims. You all were reimbursed in error. Our examiner made a mistake when they processed that payment to you because it never should have been processed. It should have been denied.
[CUSTOMER][NEUTRAL] Which is
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] As it was the second time around, citing submit a primary EOB that shows a payment in the form of a co-pay, co-insurance or deductible, not a denial, OK?
[CUSTOMER][NEUTRAL] Yeah, so we submitted that EUB where it shows the whole allowed amount was processed and allowed by the primary insurance and applied to a patient's deductible.
[CUSTOMER][NEUTRAL] Which applied here PR one, which is deductible. So we send that UB again.
[CUSTOMER][NEUTRAL] To reprocess the claim.
[CUSTOMER][NEUTRAL] The primary primary insurance has already reprocessed that denial and applied this allowed amount to patient deductible. So that deductible EUB has been already sent.
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] Let's see here.
[CUSTOMER][NEUTRAL] I think that's what the EU you have seen, uh, that you received. So you send it back for a further investigation or for review.
[AGENT][NEUTRAL] OK, let me put you on a brief hold and see if I can get the uh processor on the line for you. One moment, OK? Thank you.
[CUSTOMER][NEUTRAL] Sure, sure. You're welcome. You are on hold.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] HPO. My name is [PII]. How may I help you?
[AGENT][NEUTRAL] Hi [PII]. This is [PII] over in the cancer department. I have, I have Mr. [PII] on the line. Uh, this is regarding policy number 195.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] 479 5.
[AGENT][NEUTRAL] For uh part two Larami Rumble. OK, so I reviewed your messages because I know I sent you an email, uh, some time back and said that the claim had originally been voided. It looks like, you know, we needed to reprocess it, but then I reviewed your notes and you're saying in your notes that in other words, it never should have been paid in the first place because we didn't have an EOB that was showing the patient's responsibility, OK?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] But he and I see where you reached out to him and I explained all that, read your notes that you reached out to him and someone named [PII] or [PII] [PII], and uh he's saying that the ELB that they submitted that was denied is DM 37 shows that the total amount went toward the patient's deductible.
[AGENT][NEUTRAL] But the notes are showing that it says PI 197, but at the top of this EOB it says patients responsibility code is PR1. So I don't know what at this point I've gone as far as I can go because I don't know how you all do it in Metlink. The top is saying PR1, which clearly is a patient deductible. It's showing in the patient deductible column. So I'm gonna pass them along to you for you to further assist them, OK? Because I've gone as far as I can.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] That's fine. Yeah, I had to ask [PII] about it too. Yeah, I understand. Uh, that's, uh, that's why, uh, yeah, if you don't mind singing to me.
[AGENT][NEUTRAL] OK, yeah, because it, I know, I know, I, it gets because it gets, you know, I used to do Metlink but I haven't done it in a while, but, um, I still know somebody over there and I know sometimes it's confusion about these uh ELBs and what they're showing and the codes that's on here and I just think this is one of them at the bottom it's saying PI 197 and then at the top it's saying PR1 so I don't know mhm yeah.
[CUSTOMER][POSITIVE] Right, it is very confusing, yeah, so absolutely, [PII], if you don't mind sending them on to me, I'd be glad to help.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] OK, and I've, I've verified everything for him and I'm gonna put a note in there so you'll see his callback number and everything OK [PII] and I thank you so much here he comes right, one moment.
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Mr. [PII]?
[AGENT][NEUTRAL] Mr. [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] I have Miss [PII] on the line and she's gonna further assist you. Thank you for calling APL you have an awesome weekend and take care, OK?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] All right. Thank you, [PII].
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] [PII], yes, I