AccountId: 011433970860
ContactId: 745c7be3-c65a-4a6f-bcc6-722326f08837
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 983059 ms
Total Talk Time (AGENT): 395891 ms
Total Talk Time (CUSTOMER): 259313 ms
Interruptions: 5
Overall Sentiment: AGENT=0.5, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/08/745c7be3-c65a-4a6f-bcc6-722326f08837_20250408T16:54_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How can I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] on the care team and I've got a primary insurance on the line um she's trying to help the insured because there was a claim that we denied and the primary explanation of benefits was submitted, but.
[CUSTOMER][NEUTRAL] I can't figure out what exactly is missing on the claim matching up to the EOBs of the primary.
[AGENT][POSITIVE] OK, I'd be happy to take a look. [PII], can you give me the policy number please?
[CUSTOMER][NEUTRAL] Uh, policy number is 769779.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then I've got um [PII] on the line from the primary insurance.
[CUSTOMER][NEUTRAL] Um, the EOBs and I can give you the claim number.
[AGENT][NEUTRAL] OK, go ahead with that claim number.
[CUSTOMER][NEUTRAL] Claim number is 3,583,910.
[AGENT][NEUTRAL] And it's uh you said [PII] is uh the provider?
[CUSTOMER][NEUTRAL] Yes, [PII] is with the primary uh insurance.
[AGENT][NEUTRAL] And Ms. [PII], OK.
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And what's a good call back number they gave you? Is that the number on the screen there?
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Uh, it's [PII] no, it's [PII].
[AGENT][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, and so we're trying to match up the information for that claim 358.
[AGENT][NEUTRAL] 3910.
[AGENT][NEUTRAL] And, um, with
[CUSTOMER][NEUTRAL] Yeah, I just have
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] Go ahead.
[CUSTOMER][NEGATIVE] I just couldn't decipher what exactly is missing or what's not matching.
[CUSTOMER][NEUTRAL] According to the EOBs, so.
[CUSTOMER][NEUTRAL] So I was just gonna see if you could help her walk through it.
[AGENT][NEUTRAL] Yeah, yeah, it looks like the surgery and the imaging for [PII] on imaging and [PII] on the surgery. OK, I pulled up the um mail itself so I can go ahead and take a peek through it. If you wanna go ahead and transfer him and uh the patient information was verified, [PII].
[CUSTOMER][POSITIVE] Yes it was yes, I did get that verified, yep. OK, well thank you so much.
[AGENT][POSITIVE] OK, great.
[AGENT][POSITIVE] All right, well you can go ahead and you're welcome have a great day.
[CUSTOMER][NEUTRAL] You too.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Hi, hi, this is [PII]. I'm on the claim support team. Am I speaking with [PII] and Ms. [PII]?
[CUSTOMER][NEUTRAL] Oh,
[CUSTOMER][NEUTRAL] Uh, it's just [PII] on the line, um, but I am calling in representation of Miss [PII] from her, uh, primary insurance company, Louisiana Blue.
[AGENT][NEUTRAL] OK, got you. OK, just give me one moment please, uh, I'm reviewing the information looks like we were needing uh.
[AGENT][NEUTRAL] A detailed explanation of benefits. So I'm in the process of going ahead and reviewing that information. So if you'll bear with me for just one moment please, [PII], and again my name is [PII]
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][POSITIVE] Take your time.
[AGENT][NEUTRAL] OK it looks like we were needing.
[AGENT][NEUTRAL] The imaging.
[AGENT][NEUTRAL] For 10 1
[AGENT][NEUTRAL] And then there was also it appears a surgery on [PII] and I'm looking at that now.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Now I believe um on the for the 101 data service it's showing the hospital facility visit so it's not, it didn't break it down for the type of service as imaging um.
[AGENT][NEUTRAL] Let me just take a look and see.
[AGENT][NEUTRAL] OK, so, um, on that 101 data service, um, for it looks like imaging, the charges didn't match what was on the explanation of benefits, so that's why we're asking for that detailed, uh, explanation of benefits. So on the 101 we're looking at the claim detail, it shows the Christa's Health Shreveport.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, 101 is a data service that shows hospital slash facility visit and then it has the amount um charged is 8,568, but uh it looks like the charges were.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 5326.
[CUSTOMER][NEUTRAL] So the 8,568 is for all of the services done that day there were 5 claim there are 5 lines on the claim.
[CUSTOMER][NEUTRAL] So that's the total charge for all 5 lines.
[CUSTOMER][NEUTRAL] And then the actual allowed amount for the lines was the $3,878.68.
[AGENT][NEUTRAL] OK, because it it looks like just give me one moment.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] OK, now I, I do see that it's on the billing, not sure.
[AGENT][NEUTRAL] Looks like they broke down the services but.
[AGENT][NEGATIVE] Not sure why they would.
[AGENT][NEUTRAL] Not add those two amounts together.
[CUSTOMER][NEUTRAL] What two amounts?
[AGENT][NEUTRAL] Uh, well, I'm sorry, the, the, uh, I'm sorry, all the charges, the 5 charges like you said.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] Sorry, my apologies.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh no, you're fine.
[AGENT][NEUTRAL] OK, and so then this uh surgery amount, I'm looking at that now.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] And this one they didn't even put the amount incorrectly.
[AGENT][NEUTRAL] So,
[AGENT][NEUTRAL] And so on that [PII] you're showing the total charges should be the.
[AGENT][NEUTRAL] 4:32.
[AGENT][NEUTRAL] 4433271.
[AGENT][NEUTRAL] Is that right?
[CUSTOMER][NEUTRAL] This is for the
[CUSTOMER][NEUTRAL] The biopsy, right?
[CUSTOMER][NEUTRAL] Um, because there's several charges, I'm, I'm trying to distinguish one because there's actually several charges from that day.
[AGENT][NEUTRAL] Yeah, [PII], yeah, [PII], right, well, the dates of service they have in here is [PII] where they're asking for the um.
[CUSTOMER][NEUTRAL] This is just a lab work, OK, it should be that.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] For the October for for this one it has the
[CUSTOMER][NEUTRAL] This one when she did the biopsy, it was the total charge was $4,704.60.
[CUSTOMER][NEUTRAL] The allowed amount was $3,718.94.
[CUSTOMER][NEUTRAL] And then we left, we paid $3,347.05 and left $371.89 in coinsurance.
[AGENT][NEUTRAL] OK, I did see that on the EOB.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I think it's a little bit confusing the way they.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Process all the charges, but I do see, so 10, let me see.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Sometimes it's broken down like when there's multiple lines on the claim they'll break down the dates on the EOV.
[CUSTOMER][NEUTRAL] Um, for the individual lines, but it won't tell you the directly like this is this, this is, you know, like a, a complete breakdown.
[AGENT][NEUTRAL] So those charges include the supplies as well?
[AGENT][NEUTRAL] For the surgery itself?
[CUSTOMER][NEUTRAL] Uh, it looks as if, yeah, cause the other ones are the lab test, yeah, cause everything else is just the lab test and the ultrasound that's on a different claim.
[AGENT][NEUTRAL] Yeah, 4761 95.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So yeah, it looks like that includes everything on that one.
[AGENT][NEUTRAL] Because it looks like there's a and I think that there it I think that.
[AGENT][NEUTRAL] There's some confusion too because there's is those are those professional fees on there as well possibly?
[CUSTOMER][NEGATIVE] Not on this one. The professional fees are billed separately.
[AGENT][NEUTRAL] But
[AGENT][NEUTRAL] For the EOB.
[AGENT][POSITIVE] They are OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It may be on the same because I'm having trouble pulling up the EOB. The system is acting weird on the system. It may show from the same date, the professional, but it's a separate claim because the claim numbers were showing it, but they did a separate claim for the professional fees.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, because I'm coming up with a different amount. So you said those surgery charges should be what's on that line 4 I'm sorry 470,460, correct?
[CUSTOMER][NEUTRAL] Yeah, that's the total bill amount, mhm.
[AGENT][NEUTRAL] And then the coinsurance uh leftover was the 37189 that shows on that EOB.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Cause like I said, they adjuster when she processed it included some additional er uh some additional charges and didn't break it down by just the surgery itself because there's another line for a [PII] for $280 for the surgery.
[CUSTOMER][NEUTRAL] That's the um that's the professional, yeah, that's the professional charges.
[AGENT][NEUTRAL] And the EOB
[CUSTOMER][NEUTRAL] But it has a different claim number.
[AGENT][NEUTRAL] And that
[AGENT][NEUTRAL] So we should be able to match up that claim number.
[AGENT][NEGATIVE] On the itemized.
[CUSTOMER][NEUTRAL] Yeah, it should have the claim numbers right underneath, uh, where it says the provider name. It should have the claim number listed and you should be able to match that up with, um, with the lines of the claims.
[AGENT][NEUTRAL] Or
[AGENT][NEUTRAL] 242-5216.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So what I can do at this point, uh, [PII], is I can send this back to the adjuster to have a review, um, because she's asking for more detailed, um, I I, uh, excuse me, explanation of benefits, but like you said.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It doesn't because she's saying it doesn't list the copay and deductible amounts but it does on the explanation of benefits like you said it does show that amount so what I'm gonna do is send it back to the adjuster and have her review those services um and let her know that there's some additional charges that she included when she keyed the claim that should be under the professional fees, um.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then, so I'm gonna have her review both the imaging for 101 and the surgery, uh, which is the biopsy on [PII].
[CUSTOMER][POSITIVE] OK, I'm writing that down so I can.
[AGENT][NEUTRAL] And it's usually um yeah it's usually a 1 to 3 day um.
[AGENT][NEUTRAL] Turn around to have this reviewed um but I will go ahead and get it um done today and the number I have for contact [PII], is that a good number to contact you if need be?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That's our um custom direct customer service number because we don't have individual numbers so if you call that number just ask to speak with me um and then uh if I'm not available an agent can see the notes that I have in there that's why I like to put detailed notes, um, but, uh, you can call that number just ask to speak with [PII], um, and then if I'm not available they can review the notes and be able to see the details as to what we were discussing.
[CUSTOMER][POSITIVE] Or you can call the member back directly either one because the, the member will be up. I'm gonna call him back as soon as we get off the phone.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and you can just uh let her know like I said that we'll have this reviewed um as soon as possible and um if there's anything additional, um we'll reach out um but like I said it, it, it matches up with what you're telling me and like I said, there is some um additional uh services that were also included that doesn't give the right amount for that surgery.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] Um, so if I can just, um, point her attention to that and just make sure that she um realizes that those other services are professional fees.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] OK, did you have any other questions, [PII]?
[CUSTOMER][POSITIVE] Alright, I will let him. No, that's all. Thank you so much for your help.
[AGENT][POSITIVE] You're welcome. Thank you so much for your patience and thank you for calling API. I hope you have a great rest of your day.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][POSITIVE] You too alright bye.
[AGENT][POSITIVE] Thank you bye bye.