AccountId: 011433970860
ContactId: 65d3faa1-6ce5-4cfe-96b6-1bac19c63296
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1137630 ms
Total Talk Time (AGENT): 462221 ms
Total Talk Time (CUSTOMER): 562346 ms
Interruptions: 20
Overall Sentiment: AGENT=0.4, CUSTOMER=1.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/02/65d3faa1-6ce5-4cfe-96b6-1bac19c63296_20250502T20:33_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII] with Legacy Financial Consulting. Um, we're the, I'm the agent of record for a member that has a gap policy with you all and she's having an issue with a claim, so I was hoping to see if you could review it with me, uh, quickly.
[AGENT][NEUTRAL] OK, then you, so you're needing to go over a claim for a member, is that correct?
[CUSTOMER][POSITIVE] Correct. That's correct.
[AGENT][POSITIVE] Yes, ma'am. I can help you with that. And [PII], what is the callback number for you?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] OK, thank you. And the patient's policy number?
[CUSTOMER][NEUTRAL] The policy number is 245-0372.
[CUSTOMER][NEUTRAL] It's for um one of his children.
[AGENT][POSITIVE] OK, thank you. OK.
[AGENT][NEUTRAL] OK, so give me a moment please to get the information pulled up and I will have to verify several things with you. I'm sure you're already aware of that for security.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][POSITIVE] No problem. Yes, yes, don't worry, I'll give you all the details.
[AGENT][NEUTRAL] Ah.
[AGENT][NEUTRAL] OK, so just.
[CUSTOMER][NEUTRAL] They need their height or weight. I have it all.
[AGENT][NEUTRAL] Pretty much, yeah, pretty much just stay in time, we do have to verify a lot. OK, so first off, on this, um, tell me again who you are with one more time, [PII].
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] I know.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I'm with Legacy, yes, of course, Legacy Financial Consulting we're the agent of record for the uh members company which is Folio Title.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, yeah.
[AGENT][NEUTRAL] OK, thank you. And then do you spell your name with a [PII]?
[AGENT][NEUTRAL] How do you spell your name?
[CUSTOMER][POSITIVE] It's, yes, that's correct. It's with a [PII] that's correct. It's [PII], yeah.
[AGENT][NEUTRAL] OK, yeah, 2.
[AGENT][NEUTRAL] OK, thank you. And then your last name, please?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] OK, thank you. And then what is, who is the agent of record on this group?
[CUSTOMER][NEUTRAL] It's [PII] with Legacy Financial Consulting.
[AGENT][NEUTRAL] OK, and
[AGENT][NEUTRAL] Thank you and then your email address?
[CUSTOMER][NEUTRAL] It is [PII].
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] OK, and then what is the patient's name and date of birth?
[CUSTOMER][NEUTRAL] The patient is [PII] and her date of birth is [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, and again, as you know, any information that I do provide for you, [PII] would be a verification of benefits and not a guarantee of payment. So what is the date of service and total bill amount for this member? Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Of course.
[CUSTOMER][NEUTRAL] Date of
[CUSTOMER][NEUTRAL] So date of service was [PII]. Um, she was seen at an urgent care, um, it's called CityMed. Let me make sure that's correct, yes, City MD sorry, City MD urgent care, um, she paid out of pocket she didn't have her APO card with her at the time, so she paid out of pocket, um, so her mother submitted.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The receipt and the claim report um she just received the EOB from AMed so I just did submit that I think it might have some of the details that were um might be missing.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so now for you did say the patient is [PII]?
[CUSTOMER][NEUTRAL] Correct, [PII].
[AGENT][NEUTRAL] And you said the data service is.
[AGENT][NEUTRAL] 48.
[CUSTOMER][NEUTRAL] [PII] I'm sorry, [PII] [PII], sorry about that.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] Oh, OK, because I was gonna say, we don't have a claim for the [PII]. OK.
[CUSTOMER][NEUTRAL] [PII] is my mother's, no [PII] is my mother's birthday, so I might have said [PII] by, you know, by accident.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] Uh, OK. OK, that's all right then. OK, so just one moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So let me look at some of the different information.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] What is the provider's name?
[CUSTOMER][NEUTRAL] It's MD City, but it was specifically there was a charge from a uh hold on I have the name of the.
[CUSTOMER][NEUTRAL] It is 1 2nd. [PII] is the doc, the physician who attended her at the urgent care.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. All right, so let's.
[AGENT][NEUTRAL] OK, so I can see.
[AGENT][NEUTRAL] Mm, yeah, and what was the bill amount?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, the full bill amount was 482. However, what she paid, she actually overpaid. They're gonna be reimbursing her half of the money. She paid $250 but the patient responsibility is 125, which is the the urgent care co-pay.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] OK, so I, let's see.
[AGENT][NEUTRAL] Let me look at some of these good because these are not I don't have a claim for that bill amount.
[CUSTOMER][NEUTRAL] Let me see if he.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Yeah, this is every I have everything she submitted and the total bill amount hold on a second because I have the EOB here from APL one second and it does say, let me see what it says. It says [PII], page 2 is there a page one to this? Did she send me page one.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] There is a reference number on the EOB from AAPL that you received. Will that help you?
[AGENT][NEUTRAL] You can give me that claim number. Mhm.
[CUSTOMER][NEUTRAL] Claim oh actually claim number is 359-492-6.
[AGENT][NEUTRAL] OK, so I am looking at that one.
[AGENT][NEUTRAL] Um, now, on.
[CUSTOMER][POSITIVE] OK, excellent.
[AGENT][NEUTRAL] But the bill amount on that is not 482.
[CUSTOMER][NEUTRAL] That's what's on the hm let me see.
[AGENT][NEUTRAL] That's
[AGENT][NEGATIVE] It, yeah, that's not what that should.
[CUSTOMER][NEUTRAL] Well, she submitted, she submitted the, the complete bill which all the way, oh well, maybe, let me see, 150, 150, 30. It shows 482 is the total charge um outstanding and then she paid at the appointment $250 which is the, their urgent care, I guess, amount for the facility.
[CUSTOMER][NEGATIVE] She overpaid because obviously Amed processed the claim and her, her co-pay should have only been 125. They're going to the urgent care is going to reimburse her the, the amount, the overcharge. However, she did, and it, you know, she paid the, the urgent care co-pay, so she's just trying to get reimbursed for that 125.
[CUSTOMER][NEUTRAL] Which was her responsibility.
[CUSTOMER][NEUTRAL] And I did submit the EOB um through the APO portal.
[AGENT][NEUTRAL] And that, OK.
[AGENT][NEUTRAL] OK, so I, OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so give me just a second because in looking at what's in the system, the billed amount on that claim number is not 482.
[CUSTOMER][NEUTRAL] 35
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] OK, give me a second. Let me see if I see something different here, so she sent me the backside of the EOB which showed.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, office visits are not covered.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Insured primary insurance provided full benefits. There are no benefits. Right. The issue is they did submit as a uh office visit but there's a there's another code that shows it's urgent care.
[AGENT][NEUTRAL] Full benefits, no benefits. Correct.
[CUSTOMER][NEUTRAL] Um, so that's why I sent the, the EOB that just arrived yesterday from AMed.
[CUSTOMER][NEUTRAL] And again, it does show her responsibility is the 125, which is the urgent care co-pay.
[AGENT][NEUTRAL] OK, so yes, based on, OK, so based on what we have have reviewed at this point, [PII], um, yes, it was as an office visit, not as, and so that was denied because office visits are not covered.
[CUSTOMER][NEUTRAL] Mhm, mhm, mhm.
[AGENT][NEUTRAL] So
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I can see that you did, uh, I can't see the document, but I can see that there has been a document uploaded on, um,
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII]'s profile.
[AGENT][NEUTRAL] So that will be reviewed for this data service.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] But I'm trying to
[AGENT][NEGATIVE] See where this amount came from and my information will not load for some reason.
[AGENT][NEUTRAL] So bear with me just a second. I'm still trying to.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, let me go about this the long way. Bear with me just a second.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Again, the total bill amount from the doctor's office, um.
[CUSTOMER][NEUTRAL] All she's trying to do is get reimbursed the uh the 125, which is what the patient responsibility is because she paid.
[CUSTOMER][NEUTRAL] Actually more than that, she paid double.
[CUSTOMER][NEUTRAL] But she's gonna get reimbursed by the, uh, they're crediting her, the urgent care is crediting her the, um the extra 125, so she's just trying to make sure that she gets reimbursed for the 125.
[AGENT][NEUTRAL] What
[CUSTOMER][NEUTRAL] Oh good, I'm not the only one.
[AGENT][NEUTRAL] So
[AGENT][POSITIVE] I'm sorry about that. I am so sorry. You would, no one will ever listen. No, but no one would ever listen to a call until this very moment after all of these years and hear that in the background. I had to very unexpectedly babysit my son's, um,
[CUSTOMER][NEUTRAL] No. Listen, I don't know, I don't know if you've heard my puppy, but I have a new don't worry.
[AGENT][NEUTRAL] Girls we'll call them and they're Belgian Malimoises.
[CUSTOMER][NEUTRAL] Uh-huh, OK.
[AGENT][NEUTRAL] They're yeah they're police dogs. And so, and so yes, they
[CUSTOMER][NEGATIVE] Oh my gosh. Yes, they're very loud.
[CUSTOMER][POSITIVE] They're very, yeah, they're very protective. They're very protective. They're very vocal.
[AGENT][NEUTRAL] They have not made a peep until just now. I mean, they have been in my office with me as quiet as church mice, but someone apparently is here. And you know what, I just let them go and shut my office door back, so I may, who knows what I may find in my.
[CUSTOMER][NEUTRAL] This
[AGENT][POSITIVE] In other parts of my house when I get off the phone, but that's not my problem. I'm so sorry about that though.
[CUSTOMER][POSITIVE] No, it's OK. It makes me feel better because I have
[AGENT][NEUTRAL] Oh it just about gave me.
[CUSTOMER][NEUTRAL] No, I know a heart attack when you're not used to it it's, it's, it's crazy.
[AGENT][NEGATIVE] I did. I about had a, no, no. I just about jumped out of my chair.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Yeah, I have, I have a [PII] old, I have a 14 year old, which is a saint, that dog, this dog is a saint. And we just got a puppy. He's 3, he just turned 3 months old, it's an Australian shepherd, and he's trying, he's been trying to get my, my attention.
[AGENT][POSITIVE] Oh my gosh.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] Uh,
[AGENT][NEUTRAL] Oh.
[AGENT][POSITIVE] Ah bless him.
[CUSTOMER][NEUTRAL] Like quiet. I'm like quiet.
[AGENT][NEUTRAL] Oh, OK.
[CUSTOMER][POSITIVE] When your dog, when the dogs went off, I was like, oh thank [PII] I'm not the only one.
[AGENT][POSITIVE] Yes, well, I'm so, I'm just, you know, if, if I had to be on the phone with anyone at the moment and that occurred, I'm glad that it was you.
[CUSTOMER][NEUTRAL] No, it's OK.
[AGENT][NEUTRAL] I really am, but nonetheless, um, it was highly unprofessional and I'm very sorry about that.
[CUSTOMER][NEUTRAL] Yeah. Mhm.
[CUSTOMER][NEUTRAL] It's OK. It's OK.
[AGENT][NEUTRAL] Right.
[AGENT][NEGATIVE] All right, and I'm still trying to get this information to load and why I can't look at exactly what was submitted, that's what I can't see, um.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] I can't, yeah, I'm just having so.
[CUSTOMER][NEUTRAL] Yeah, so she submitted she's just to let you know, she submitted the receipt, a copy of the receipt of what she paid, and then the uh claim report which shows the total bill, you know, from AMed with the total bill amount what they paid out and what the patient responsibility is and then um submitted also in uh complete uh print out of the charges and everything from.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The facility to show that it is an urgent care. It says urgent care, um, and then
[CUSTOMER][NEUTRAL] Again, they, she hadn't received the Amed actual EOB yet. She just received that, so I went ahead and submitted it online so hopefully that will help clear up things.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Hopefully
[AGENT][NEUTRAL] OK, so what I will do is I will just make a note regarding our conversation and that this was an urgent care visit. Um, let me get back over there. But I was just trying to look at the charges since, but you just, I'm just
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][POSITIVE] Yes, of course.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Yeah. She's just trying to, all she's trying to do is get reimbursed for her 125, which is her urgent care, her urgent care uh co-pay.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] See.
[AGENT][NEUTRAL] And you said you uploaded the EOB correct?
[CUSTOMER][POSITIVE] Mhm. Correct, correct.
[AGENT][NEUTRAL] Showing that this was urgent for urgent care.
[CUSTOMER][POSITIVE] Correct, correct.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] I'm just gonna put
[AGENT][NEGATIVE] OK, so since I can't see that, so I'm just put, I put in here and tell me if this is accurate because I'm telling you those, my two fur baby grandkids have thrown me off my game. I'm wondering if I even know my name at this point. They scared me to death. I mean, I'm not even joking.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Oh my gosh. Um, so you just uploaded the EOB showing that this visit was for urgent care and, right, and that the insured is filing for reimbursement on the urgent care visit, not an office visit. Is that correct?
[CUSTOMER][POSITIVE] Correct.
[CUSTOMER][POSITIVE] Correct.
[CUSTOMER][POSITIVE] Correct. That is correct. And it's a 125 co-pay if you wanna add that.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] OK, let's see, and that was for 44.
[AGENT][NEUTRAL] Um she
[CUSTOMER][NEUTRAL] Oh, yes, correct, 2025.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] And you said the copay was 125, correct?
[CUSTOMER][POSITIVE] Mhm mhm correct.
[AGENT][NEUTRAL] OK, so I have got that uh let me make sure.
[AGENT][NEUTRAL] OK, so I have got that documented and then once they review it they should see that so um.
[CUSTOMER][POSITIVE] Perfect.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] So that's all in here. I just want to make sure that all my T's were crossed and I's were dotted.
[CUSTOMER][POSITIVE] Perfect thank you [PII] I appreciate it.
[AGENT][POSITIVE] OK. Well, you are certainly very welcome, [PII]. And is there anything else that I could help you with today?
[CUSTOMER][NEUTRAL] Um, just, I, I don't think you guys do not give reference numbers, right? It's just your name and the date if I, if I'm correct, am I correct? OK, so just [PII], right.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Uh-huh. That is correct. My name in today's date will be the reference number, yes.
[CUSTOMER][POSITIVE] Excellent.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Perfect. Thank you, [PII]. You have a nice weekend and um go, go, go, go inspect your house.
[AGENT][POSITIVE] Well, I hope you have a wonderful weekend too.
[AGENT][NEUTRAL] Oh, I'm just gonna wait until I get off. Yup, I'm, uh, it's, I don't hear any ruckus now, so that could be one of a couple of different things. I'm just gonna wait until I get off in about 10 minutes and see what may be going on in there.
[CUSTOMER][NEUTRAL] Listen, all I could say is at least you're safe.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] That's
[CUSTOMER][NEUTRAL] It's I, I, I say listen, you are safe, nothing is gonna get in your house. God, God have [PII] on the.
[AGENT][NEUTRAL] That's right. No, I'm for sure safe. I can't speak for anyone.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] Exactly. If it was someone that they really don't know, yeah, I'll just wait and find all that at [PII] when I get off.
[CUSTOMER][POSITIVE] Exactly, you have to clean up blood and body parts, don't worry.
[AGENT][NEUTRAL] Yes, yes, I have to start calling, you know, some backup. Yeah, I'm just gonna wait 10 minutes to do that.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Exactly.
[AGENT][POSITIVE] Oh, my goodness. Wow. OK.
[CUSTOMER][POSITIVE] Alright [PII] you take care.
[AGENT][POSITIVE] You too, [PII], have a wonderful weekend. OK. Thanks. Bye-bye.
[CUSTOMER][NEUTRAL] All right. You too, you too. Bye bye.
[CUSTOMER][NEUTRAL] Bye.
[AGENT][NEUTRAL] Bye.