AccountId: 011433970860
ContactId: 7ff3f26f-3126-4fb6-abc4-80ded7e1967a
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 644039 ms
Total Talk Time (AGENT): 253645 ms
Total Talk Time (CUSTOMER): 372642 ms
Interruptions: 7
Overall Sentiment: AGENT=0.5, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/12/7ff3f26f-3126-4fb6-abc4-80ded7e1967a_20250512T19:04_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How can I help you?
[CUSTOMER][NEUTRAL] Hey [PII], this is [PII] on the care team. How you doing?
[AGENT][POSITIVE] Doing well [PII] thank you how are you?
[CUSTOMER][NEUTRAL] I'm doing good um I have a provider on the other line um that wants to speak to somebody can you look at this, uh, claim?
[AGENT][NEUTRAL] Certainly.
[CUSTOMER][NEUTRAL] It is policy number 1887382.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And it's part 2.
[AGENT][NEUTRAL] For [PII].
[CUSTOMER][NEUTRAL] Yes, and it's um claim number 357-4757?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] 4757 pull up that document. OK, go ahead.
[CUSTOMER][NEUTRAL] OK, so,
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So she first called, this is the provider, first call saying that we didn't pay out to everything and I said, well, of the three codes we paid what was billed.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And then, um, I said that's what gave the total of the 277. She said, well, when there's a modifier, United Healthcare doesn't break it down or breaks it down, and we only paid half. So when I pulled it up in OnBase, I'm like, OK, well, I see what you're saying, but for the ones that don't have a modifier, they weren't billed.
[CUSTOMER][NEUTRAL] So, like there's no charge there. She said, but it still has the patient responsibility.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] When primary, if it's not built and primary didn't apply anything, they adjusted it, we're not gonna apply anything, right?
[CUSTOMER][NEUTRAL] Because we paid for the ones that were billed.
[CUSTOMER][NEUTRAL] And we
[CUSTOMER][NEUTRAL] We paid the allowed amount.
[AGENT][NEUTRAL] Right, that's the way it looks to me is.
[AGENT][NEUTRAL] So they're saying that.
[CUSTOMER][NEUTRAL] She's saying, you see how that sick the.
[AGENT][NEUTRAL] Yeah, I mean it has to, it, it has to match what's on the, the, the claim form has to match what's on the, you know, the EOB remittance advice, so um.
[CUSTOMER][NEUTRAL] You'll be.
[CUSTOMER][NEUTRAL] Right, so I said, so are you saying because I said, so are you saying because the EOB chose the modifier and without the modifier that we should have paid without the modifier, even though we were only billed those three and she said, yeah, and I said, well, I don't know.
[CUSTOMER][NEUTRAL] Wait a minute, cause that we uh from what it looks like to me, we paid what we were billed.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right, and it looks like to me also that that allowed amount was also adjusted off.
[CUSTOMER][NEUTRAL] Adjust it, right, and that's what I told her.
[AGENT][NEUTRAL] Even though it shows, even though it shows in the patient responsibility, that's not the way this EOB reflects.
[AGENT][NEUTRAL] So she's.
[CUSTOMER][NEUTRAL] Mhm and it doesn't match the claim form anyway.
[AGENT][NEUTRAL] Right, so we would have to.
[CUSTOMER][POSITIVE] OK, so at least I read it right.
[AGENT][NEUTRAL] Yeah, I mean, if you want I'll speak to them and try to explain it.
[AGENT][NEUTRAL] Since they wanna talk to somebody else. Mhm.
[CUSTOMER][NEUTRAL] Oh, yes, because she's
[CUSTOMER][NEGATIVE] Yeah, she's like, no, that's not how this works. You have to pay the patient responsibility, and I'm like, but we weren't billed for that.
[CUSTOMER][NEUTRAL] So, OK.
[CUSTOMER][NEUTRAL] We, I just want, but for me, for future, I, I did read that right correctly, I mean, right, cause we paid.
[AGENT][NEUTRAL] Yes, I mean,
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Right, yeah, I mean, as far as I can tell, yeah, no, because like I said, those bills amounts are zero, and even though there's an allowed amount, it looks like those amounts were adjusted off and then they show it under patient responsibility. However, it doesn't reflect that on the bill claim line, so.
[CUSTOMER][NEUTRAL] So that's why I question myself.
[CUSTOMER][NEUTRAL] We're adjusted.
[CUSTOMER][NEUTRAL] Right, OK.
[CUSTOMER][NEUTRAL] Well, you made that crystal clear for me. I just wanted to make sure cause I'm like, well, maybe I'm like, OK, well, I'm not in claims, so maybe I don't, she knows something I don't know then.
[AGENT][NEUTRAL] I don't know why.
[AGENT][NEGATIVE] Yeah, I mean it's a it's kind of a messed up.
[AGENT][NEUTRAL] I, I don't know why.
[AGENT][NEGATIVE] I mean they they can't, I would, I would assume that all these EOBs are not like this because they would never get paid.
[CUSTOMER][NEGATIVE] Right, and how are you? I don't even understand how this patient responsibility if it was not billed and then it was adjusted.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Well, her name is [PII], and I think she just wants to hear it from another person, and she knew I wasn't in claims too, so she felt like I didn't know what I was saying.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII], is that her callback number, the [PII] showing, or what's your callback?
[CUSTOMER][NEUTRAL] Mhm. [PII].
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII] and everything's been verified for the patient, right, [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, you can send her on through.
[CUSTOMER][NEUTRAL] Alright, hold on one second. Thank you, [PII]. Thanks for explaining that to me because I was doubting myself. Alright, hold on.
[AGENT][POSITIVE] Sure. You're welcome.
[AGENT][POSITIVE] Yeah, you're welcome.
[AGENT][NEUTRAL] Right
[AGENT][NEUTRAL] I could see why.
[CUSTOMER][NEUTRAL] Alright, hold on one second.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Hello, [PII]. Yes. Thank you so much for holding. I have [PII] on the line and she'll be assisting you further, OK? OK. Thank you, [PII]. You're welcome.
[AGENT][NEUTRAL] Hi, [PII].
[CUSTOMER][NEUTRAL] Hello, [PII].
[AGENT][NEUTRAL] Hi, can you hear me OK?
[CUSTOMER][NEUTRAL] Hi, how are you?
[AGENT][POSITIVE] I'm doing well thank you how are you?
[CUSTOMER][POSITIVE] Yes, I was good, good. I was trying to explain uh uh what United those.
[CUSTOMER][MIXED] Uh, it's very confusing, but they get the um.
[CUSTOMER][NEUTRAL] The procedure and they paid the unit, you know, 100% 1st and then they add another line for the 50% because those claims were those procedures were um billed bilateral.
[CUSTOMER][NEUTRAL] So what they do is for example a 6 or 493 they allow 180 to 52 that's the allowable for one side and then they add an extra 9126 for the 50%.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And the same for 64494. If you add, uh, if you have the uh the original EOB of the premier insurance, you see the patient responsibility is um 41569.
[CUSTOMER][NEGATIVE] And you pay 27727. That's why I was calling. I didn't know if I have to transfer the difference to the patient and, and I told me no that you pay everything.
[AGENT][NEUTRAL] Right, because the, the way it looks like from the.
[CUSTOMER][NEUTRAL] Yeah, it's so confusing, but they are the only insurance that
[CUSTOMER][NEUTRAL] This breakdown and
[CUSTOMER][NEGATIVE] To pose for me is also difficult, you know.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] But as you see there are two lines for 64 493 and two lines for 6 or 4941 at 100% and the second one at 50.
[CUSTOMER][NEUTRAL] Footage for year.
[CUSTOMER][NEUTRAL] So the difference I missing is 13842.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] 13842.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Now is this something that United Healthcare does, uh, you said it was United Healthcare, correct?
[CUSTOMER][NEUTRAL] Do
[CUSTOMER][NEUTRAL] Yes. This specific United Health Healthcare, the ARP Medicare Complete, always do that.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Other, you know I don't know, but the patient is the one, if she has another procedure, we're going to have the same issue.
[AGENT][NEUTRAL] Right, right, OK, so [PII], what I'm gonna do is I'm actually going to go ahead and send this back through for a review, um, and have it you know, reviewed because like I said it's a little bit confusing how there's no build amount on that, yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It's, it's, it's confusing how they do the breakdown. We bill exactly like everybody else with the modifier 50, but I don't know why they put first, uh, you know, 100% and then the other 50, yes, but if you add the patient responsibility, she will come out with an amount of 4 1569 that's the was applied to the.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] They add extra lines and then, right.
[AGENT][NEUTRAL] Right, and then when they break it in two, they actually apply the the amount as half, right?
[CUSTOMER][NEUTRAL] As a negative adjustment, you see?
[AGENT][NEUTRAL] Yeah, that half, they allow half of that first procedure and then pay on both lines.
[CUSTOMER][NEUTRAL] Yes. Mhm.
[CUSTOMER][NEUTRAL] Yeah, of course, because when you we modify modify a 50 is pay a 150% of the allowable, but instead of the combining the, the two amounts, they do first the 100% and then the 50% another line.
[AGENT][POSITIVE] Got it OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, right.
[AGENT][NEUTRAL] Yes, so what I'm gonna do again is I'm gonna go ahead and send this for review, um, and it should take, you know, usually 1 to 3 business days for the turnaround time once we send it to review and then it has to be examined and then, uh, they'll either.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Either reprocess it or they'll add some kind of an update um and if for some reason it can't be reprocessed I have the number for you at the contact of [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 2 nights
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK, OK, so [PII], I'm gonna go ahead and put that through and like I said, if for some reason we can't um get it reprocessed, we'll call you back and let you know you know what what that uh result was, yeah, and you said it was 13842 total, right? Is what we're missing?
[CUSTOMER][NEUTRAL] What to do. OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh what I miss the difference, yes.
[AGENT][NEUTRAL] Yeah. So it was the 9126.
[CUSTOMER][NEUTRAL] Because the total uh patient responsibility was 44 1569 and you paid 277 27.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Got it. OK, 13842. OK, I will go ahead and put this review, uh, request through.
[CUSTOMER][NEUTRAL] OK. [PII], uh, how do you spell your name? [PII]?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] [PII] last initial is [PII] like love and you use my name and today's date for your call reference.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, perfect. All right. Thank you, [PII].
[AGENT][NEUTRAL] And did you have did you have any other questions at this time, [PII]?
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] No, no, that's it.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] That's fine, everything is fine. OK. OK, [PII]. Have a good day. Bye-bye.
[AGENT][POSITIVE] All right, thank you so much.
[AGENT][POSITIVE] You too thank you bye.