AccountId: 011433970860
ContactId: 6e5c7f4f-2f8e-4e9e-bb5e-54fde6c17517
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 761799 ms
Total Talk Time (AGENT): 278866 ms
Total Talk Time (CUSTOMER): 164570 ms
Interruptions: 0
Overall Sentiment: AGENT=0.9, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/27/6e5c7f4f-2f8e-4e9e-bb5e-54fde6c17517_20250227T13:54_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] calling from provider's office for checking claim status.
[AGENT][POSITIVE] OK, well, I'll be more than happy to help you with the claim status, [PII], and how are you doing today?
[CUSTOMER][NEUTRAL] I
[CUSTOMER][POSITIVE] I'm good. How are you?
[AGENT][POSITIVE] I'm doing well, and may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] Yes, policy number 02511314.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And how many claims do you have in total today?
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] It's one.
[AGENT][NEUTRAL] Alrighty, can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] The smallest tower.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service for the claim you like me to check on?
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Um, yes, date of service, [PII].
[AGENT][NEUTRAL] And the total bill amount?
[CUSTOMER][NEUTRAL] I don't
[CUSTOMER][NEUTRAL] The amount is $175 even.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And can you verify the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] It's Jackson Hospital and Clinic.
[AGENT][NEUTRAL] All right, so I'm showing we received the claim on [PII]?
[AGENT][NEUTRAL] The claim number is 353.
[AGENT][NEUTRAL] 5541.
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] And on [PII], the claim was paid out to the provider, a total of $75.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Any
[AGENT][NEUTRAL] Did you need the check information?
[CUSTOMER][NEUTRAL] Oh yes.
[AGENT][NEUTRAL] OK, so it was a single check in the amount of $75?
[AGENT][NEUTRAL] The check number is 201.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 6106.
[AGENT][NEUTRAL] It was issued on [PII].
[AGENT][NEUTRAL] And it cleared on [PII]?
[AGENT][NEUTRAL] And it was mailed to [PII].
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] 12, I'm sorry, 04915.
[CUSTOMER][NEUTRAL] Uh, one moment.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, one moment.
[AGENT][POSITIVE] Mhm. Take your time.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] I see.
[CUSTOMER][NEUTRAL] The primary care.
[CUSTOMER][NEUTRAL] American 7 yeah.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] 753575.
[CUSTOMER][NEUTRAL] What is the paid amount again?
[AGENT][NEUTRAL] It was paid $75?
[CUSTOMER][POSITIVE] Thank you will receive it, sir.
[CUSTOMER][NEUTRAL] Um, did you receive the primary UB on your side? Because the balance left on your side is only $35 but you have paid $75.
[AGENT][NEUTRAL] Yes, we received the explanation of benefits. We pay the max for the benefit that they have. So, hold on one moment, let me go back to the claim.
[CUSTOMER][POSITIVE] Wow
[AGENT][NEUTRAL] So the benefit that was used was the outpatient accident and treatment for physician office, which is $75 and that's the amount that was paid. So the max was paid for this claim.
[CUSTOMER][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] She
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Yes, I'm here.
[CUSTOMER][NEUTRAL] So can you uh reprocess this payment because we are left with only $35 on our side.
[CUSTOMER][NEUTRAL] So is there any chance that you will regroup in the future?
[AGENT][NEUTRAL] No, because the maximum was paid, so we can't pay over a max amount. We can only pay $75 and that's what was paid to this balance. So the outstanding balance would be up to you as a provider, whatever your um policies are, if you write it off, if you bill the patient, um, we just can't give that determination because we're not a major medical insurance company. So that's why there is no uh patient responsibility on the explanation of benefits, but the max was paid.
[CUSTOMER][NEUTRAL] No, I'm, I'm telling that uh primary is paid and the balance amount for you guys to pay is only 35, but you have paid more than the
[CUSTOMER][NEUTRAL] Balance.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That's.
[AGENT][NEUTRAL] Well, what was charged to us was $175 and of that we paid $75.
[CUSTOMER][NEUTRAL] Well
[CUSTOMER][NEUTRAL] Mm, let me see the UB for the primary.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] No, it is just 35. Can I send the EOB? Can you reprocess this claim?
[AGENT][NEUTRAL] Um, hold on, hold on one second, hold on one second.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So what came what came over on the claim form, I just pulled up the documents that were received. So on the claim form, line one shows data service 10-16-2024, place of service 11, procedure 99214, modifier GC.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Diagnosis points are ABC charges $175. So from this bill that we received, we paid $75.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] Actually, hold on one second.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] Do you mind if I place you on just a brief hold?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEGATIVE] Come on claims.
[AGENT][NEUTRAL] I need to talk to somebody in claims just to make sure.
[AGENT][NEUTRAL] See, this is why we need to be able to call. How do you support someone and you can't call them when you need support?
[AGENT][NEUTRAL] So
[AGENT][NEGATIVE] Oh this is so ridiculous.
[AGENT][POSITIVE] This is a a phone call, quick answer.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] You know what, I'm not, I'm not, that's what they said, it's fine.
[AGENT][NEGATIVE] Because you can't call nobody anyway, so I'll just go send it to reprocess and if it's wrong, it's wrong.
[AGENT][POSITIVE] And if it's right, they'll tell her it's right.
[AGENT][NEUTRAL] Hello, Hope.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Thank you so much for holding. I do apologize for that wait. So, I do see um what you're saying the insurance company paid $140 primary.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Um, let me see.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] No, they have paid $61.06.
[AGENT][NEGATIVE] I don't even see that on this that was submitted. I mean, I can go ahead and send this back to claims to reprocess, but from what it looks like.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Was this an adjustment?
[AGENT][NEUTRAL] You said 6106?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] They roll off. Hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So did
[AGENT][NEUTRAL] I'm just gonna go ahead and send this back to claims to reprocess. If the $75 was excess, then they'll go ahead and send um they'll handle it on their end in terms of getting the difference and if it's correct, then they'll let you know that this was correct.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Alright, and Hope, was there anything else I can assist you with today?
[CUSTOMER][NEUTRAL] So how many days will this take to be get reprocessed?
[AGENT][NEUTRAL] I'll say 7 to 10 business days because that's the turnaround time, but it could be um less time than that since it's a reprocessing. I just don't know how long they would take, but they do have the 7 to 10 business days.
[CUSTOMER][NEUTRAL] OK. Mm.
[AGENT][NEUTRAL] Would you like me to make this urgent? I can make it urgent.
[CUSTOMER][NEUTRAL] No, no, it's fine. And um do you have a reference number for the call?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Sure, so there's no call reference number, but you can use my name, which is [PII], first initial to my last name is [PII].
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You're very welcome. Was there anything else I could assist you with today?
[CUSTOMER][NEUTRAL] No, that would be all for now.
[AGENT][POSITIVE] Alright, well thank you so much for calling APL Hope, and I hope you have a great day.
[CUSTOMER][NEUTRAL] You too. Bye.
[AGENT][POSITIVE] Thank you. Bye bye.