AccountId: 011433970860
ContactId: 78a32346-6f97-41b9-86d6-e97872ca7056
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 788409 ms
Total Talk Time (AGENT): 222800 ms
Total Talk Time (CUSTOMER): 224304 ms
Interruptions: 1
Overall Sentiment: AGENT=0.7, CUSTOMER=-0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/22/78a32346-6f97-41b9-86d6-e97872ca7056_20250522T16:43_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 there um I'm [PII]. I'm calling from Southeast Iowa Regional Medical Center and I have a letter that we received from you guys um it looks like requesting a refund and I was just calling to inquire about that because um there's not really an explanation on here.
[AGENT][NEUTRAL] OK, well, I can definitely look into the claim and the payment and um see what's going on there. And [PII], may I have a good contact number in case we're disconnected and the policy number?
[CUSTOMER][NEUTRAL] Yeah it's [PII] and then the patient's policy number is 02006487.
[AGENT][POSITIVE] Thank you. Hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yeah it's [PII] I think it's.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Mhm, mhm.
[CUSTOMER][NEUTRAL] [PII] and then the um 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 hold on one moment.
[AGENT][NEUTRAL] This is for um an explanation of benefits that I have 3600902.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, do you mind if I place you on just a brief hold while I see what this is for?
[CUSTOMER][NEUTRAL] Yeah, that's fine.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] So it is.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mm mm mm mm.
[AGENT][NEUTRAL] Are they saying we overpaid?
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Wait, what is that?
[AGENT][NEUTRAL] Are we saying we paid 1 let me look at the notes.
[AGENT][NEUTRAL] 902441.
[AGENT][NEUTRAL] 5:50, 4:15.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hey [PII], how are you doing?
[CUSTOMER][POSITIVE] I'm good how are you?
[AGENT][NEUTRAL] I'm good. It's [PII]. Um, can you help me with this refund claim?
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Um, it's policy number 20064887.
[CUSTOMER][NEUTRAL] Part one.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, the, the original claim is 3595515.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, 5515. OK, so we originally paid 264.
[AGENT][NEUTRAL] And then that last
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Midli claim, OK.
[AGENT][NEGATIVE] I found the letter in OnBase explaining why we need the refund, but it's to the patient. Am I supposed to be telling this to the provider?
[AGENT][NEUTRAL] Because the provider is on the line.
[AGENT][NEUTRAL] I just didn't know if I was allowed to tell the provider.
[CUSTOMER][NEUTRAL] 5515 well we paid the provider initially.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So the refund, so the insured will also get a letter?
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] Yeah, hang on let me pull this up and kinda see what's going on here.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Alright, so we're requesting $91.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 173 and 91.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Oh, I see the one for the provider here. I just clicked on the one for the patient.
[CUSTOMER][NEUTRAL] Yeah, so, oh, OK, so we're requesting a refund for that G code because that's not a covered service, so we wouldn't have covered, we wouldn't have provided payment for that $91 that would have been paid, so that's why.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. I just didn't.
[CUSTOMER][NEGATIVE] Because we're, we're not gonna pay benefits for non-covered services.
[AGENT][NEUTRAL] Right, OK, I just clicked on the page and I'm like, should I tell them this, but I didn't see the, I didn't see this letter here for the provider, so I'm like, I don't know if I should tell them or not. OK, well, thank you.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yup.
[CUSTOMER][POSITIVE] You're welcome.
[AGENT][POSITIVE] All right. Have a good day.
[CUSTOMER][NEUTRAL] Alright. You too.
[AGENT][NEUTRAL] Bye bye.
[CUSTOMER][NEUTRAL] Bye.
[AGENT][NEUTRAL] Hello, [PII].
[CUSTOMER][NEUTRAL] Yeah, I'm still here.
[AGENT][NEUTRAL] All right, thank you so much for holding. I apologize for that wait. I was speaking with um a claims examiner as well. Um, but on [PII], you may not have received the letter yet, but on [PII], we sent you all a letter explaining that for code G 0463, we paid out on this code, but it's not a covered code on the policy. There was an audit that happened and it picked this up. Um, so we had to
[AGENT][NEGATIVE] Request a partial refund for the code that's not covered by the policy. We should not have paid out on that.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] So is it patient responsibility?
[AGENT][NEUTRAL] Well, uh, we don't determine patient responsibility because we're not the major medical, um, but if you all have to bill, um, that, that would be up to you as the provider.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] So did they process the secondary then?
[AGENT][NEUTRAL] Yes, we are secondary.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] You mean because of it?
[CUSTOMER][NEUTRAL] So yeah, 30 years.
[CUSTOMER][NEUTRAL] Who love the OK, hold on just a second. We're, we're just looking at something real quick.
[AGENT][POSITIVE] Sure, take your time.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Do you know if Blue Cross reprocessed that?
[AGENT][NEUTRAL] I do not, if we, if um if they did, because they won't send us an explanation of benefits, the, the provider, they'll send it to the provider, the provider will send it to us, but we haven't received anything in reference to major.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] 91.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] That's what they're gonna have
[CUSTOMER][NEUTRAL] OK, so.
[CUSTOMER][NEUTRAL] They
[CUSTOMER][NEUTRAL] We
[CUSTOMER][NEUTRAL] OK, so we'll just have to bill the patient the $91 then?
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] I think that's the refund address to verify. OK, um, just so we can send the refund to the correct address, is it the [PII]?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, that's correct. Zip code [PII].
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and that $91 that was um.
[CUSTOMER][NEUTRAL] That went to the deductible, so that would be patient responsibility then.
[AGENT][NEUTRAL] I, I can't say yes, OK.
[CUSTOMER][NEUTRAL] Cos
[CUSTOMER][NEUTRAL] Well we wouldn't leave sorry [PII]'s training, so we wouldn't leave a balance. I mean, I know you're saying that there's no responsibility left, but if you're processing a secondary.
[CUSTOMER][NEUTRAL] We have to go off with Blue Cross left.
[CUSTOMER][NEUTRAL] And they left 91 to the deductible on the G0463.
[CUSTOMER][NEUTRAL] So that would be what's left over, so that would be a patient balance.
[AGENT][NEUTRAL] Right, I'm, I'm, I agree with you. I just can't say yes, that's patient responsibility or yes, the patient has to pay because we don't determine that, but that, yes, what you're saying is, I mean.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] I can't say yes to that. We don't determ patient responsibility.
[CUSTOMER][NEUTRAL] OK, I just didn't know like.
[CUSTOMER][POSITIVE] OK, sounds good thank you and name and reference OK.
[AGENT][NEUTRAL] You're welcome. Well, was there anything else I can assist you with today?
[CUSTOMER][NEUTRAL] Um, can I just grab a reference number from you real quick?
[AGENT][NEUTRAL] Sure. OK, so there's no call reference number, but you can use my name in today's date. So that's [PII]
[AGENT][NEUTRAL] The first initial to my last name is [PII].
[AGENT][NEUTRAL] And then today's date.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, all right, sounds good thank you so much.
[AGENT][POSITIVE] You're welcome, [PII]. Was there anything else I can help you out with today?
[CUSTOMER][POSITIVE] No, we're good thank you.
[AGENT][POSITIVE] All right. You're welcome. Have a great day and thanks for calling APL.
[CUSTOMER][NEUTRAL] You too bye.
[AGENT][POSITIVE] Thank you. Bye-bye.