AccountId: 011433970860
ContactId: 835659d1-b393-48e7-9c94-64465ee85f29
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 799070 ms
Total Talk Time (AGENT): 316798 ms
Total Talk Time (CUSTOMER): 306725 ms
Interruptions: 5
Overall Sentiment: AGENT=0.4, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/16/835659d1-b393-48e7-9c94-64465ee85f29_20250516T15:52_UTC.wav
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[AGENT][NEUTRAL] Calling APL, this is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII]. I am calling with a provider's office. Um, I had some faxed in a dispute and I haven't received any update on it yet.
[AGENT][NEUTRAL] Can I have the callback number for your billing and that policy number?
[CUSTOMER][NEUTRAL] It's [PII].
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Policy is 02388488.
[AGENT][NEUTRAL] Can you verify the patient's name and date of birth, and I'll be able to assist you.
[CUSTOMER][NEUTRAL] Um, this is for [PII], I don't, I'm not sure about that part, um, 42577.
[AGENT][NEUTRAL] And is there a data service that you're calling in regards to?
[CUSTOMER][NEUTRAL] It is 10:31 of 24.
[AGENT][NEUTRAL] And what is your procedure code?
[CUSTOMER][NEUTRAL] Um, actually there's 2 92083.
[CUSTOMER][NEUTRAL] And 99214.
[AGENT][POSITIVE] Thank you. 672.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So you you're calling in regards to an appeal that you sent over after the the claim was processed with our decision?
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] So I'm not showing it on file so it has to be in the appeal department.
[AGENT][NEGATIVE] Because the only thing that I show for the date of service of [PII] is the claim that we processed and then there was no payment made. It was a $50 payment, but then there was no payment on the 92089208383 because the benefits were maxed out because the policy only pays $50 per visit.
[CUSTOMER][NEGATIVE] Oh, I don't even show we've received 50.
[AGENT][POSITIVE] Oh wow, so let me give you the check number.
[CUSTOMER][NEUTRAL] Oh, I'm sorry, yes, I do. Hold on. I just see it, yeah, that's there. OK, but you didn't receive a dispute?
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] When did you send it over?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, I faxed it on [PII].
[AGENT][NEGATIVE] And the last thing we received for this.
[AGENT][NEUTRAL] It was back in January.
[AGENT][NEUTRAL] Do you know where you sent it over to?
[CUSTOMER][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] I sent it. I talked to [PII] the last time, and I sent it to [PII].
[CUSTOMER][NEUTRAL] She told me to put it to her attention.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So I did.
[AGENT][NEUTRAL] Give me one moment.
[CUSTOMER][NEUTRAL] I spoke with A [PII], OK.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] I know I know.
[AGENT][NEUTRAL] She basically gave you the mailing address.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Fax number. So I'm not, I don't show anything on file or attached to this member's policy.
[CUSTOMER][NEUTRAL] Where you guys received anything?
[AGENT][NEUTRAL] Yes, ma'am. That's correct. I don't show anything.
[CUSTOMER][NEUTRAL] OK, because we've already sent it before.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] What is timely or so is the basically the rest of this, the patient's responsibility.
[AGENT][NEUTRAL] There's no time to silence.
[AGENT][NEUTRAL] So being that we're not a primary insurance company, we can't tell you that. The only thing that I can actually tell you is that you submitted a claim here for.
[AGENT][NEUTRAL] The total bill amount of.
[AGENT][NEUTRAL] Looks like 900 and some dollars, $1000.
[AGENT][NEUTRAL] Almost $1000 900 dollars and some dollars, and we only pay $50 which is the benefit amount for the policy is $50 per visit. The policy is only $50 per visit.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. So it's up to us what we bill the patient then.
[AGENT][NEUTRAL] I guess.
[CUSTOMER][NEUTRAL] So basically you guys are saying it's up to us what we bill the patient.
[AGENT][NEUTRAL] Um, basically I'm just telling you that we made a payment of $50 on the bill that you guys sent over for $900 and some dollars.
[CUSTOMER][NEUTRAL] Is that correct?
[CUSTOMER][NEUTRAL] Well, normally, we can't build the patient unless you guys say we just can't tell you that or it says.
[AGENT][NEUTRAL] Cause I can't tell you that because this is not a primary insurance company.
[CUSTOMER][NEUTRAL] So there's nothing that says we can't bill the patient?
[CUSTOMER][NEUTRAL] I understand you're probably kind of like um.
[CUSTOMER][NEUTRAL] It's not a regular insurance company, it's kind of like a third party off to the side one. So are you guys one of those companies where you don't go by like deductible and stuff like that?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] No, we don't, not here with this policy we don't, we do have policies like that when we are gap insurance, but this is not one of those.
[CUSTOMER][NEUTRAL] Like, OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. Can you spell your name for me?
[AGENT][NEUTRAL] Of course, [PII], and today's date, [PII], you can use my name in today's day as a reference.
[CUSTOMER][NEUTRAL] OK. OK. So you're not saying we can't bill the patient though?
[AGENT][NEUTRAL] No, I'm not saying that you can't build the patient. I'm just saying that I can't tell you if you could or you can't, but I can just.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] No, I understand what you're saying, but I have to, that's something I have to ask because if it turned out that we really can't build a patient, and then I did, then I'll get in trouble.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] So I don't on the EOB did it say something about this is a discounted rate? Yeah, that's the correct fax number.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Is that the correct fax number?
[CUSTOMER][NEGATIVE] Actually, no, it did not. No. The EOB is very vague.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The only thing it says is, I'm pulling it back up.
[CUSTOMER][NEUTRAL] Um, it has the 92083 actually it makes it look like it was billed at no money at all.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] And then just says allowed as 00 paid 0. Nothing is listed under the patient responsibility at all and then it just shows where the 99214 um.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] It was as an office visit, but the 92083, there's no charge because it's not covered.
[CUSTOMER][NEGATIVE] Doesn't even
[CUSTOMER][NEUTRAL] It is, but it doesn't, hold on.
[CUSTOMER][NEUTRAL] Right, but you have to understand on our end when an EOB comes over like that.
[CUSTOMER][NEUTRAL] It should say how much we actually build it for and then if you don't allow anything just put you don't allow it.
[AGENT][NEUTRAL] Which.
[CUSTOMER][NEGATIVE] Which they did and then, but there's nothing indicating on the EOB at all that we're even allowed to build the patient and then the 99214 doesn't even have the amount we submitted it has the amount that you guys were paying and that's it and that you paid it.
[AGENT][NEUTRAL] Mm, I think for 80 years, so it may be different.
[CUSTOMER][NEUTRAL] So it's not it's not your fault but they need to put.
[AGENT][NEUTRAL] That would be different. Let me see.
[CUSTOMER][NEUTRAL] Oh yeah, no, on this EOB it just shows submitted $50 allowed $50 paid $50. That's it.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] That's all I have. Is there anything else that you guys can give that's.
[CUSTOMER][NEUTRAL] I mean, you guys are, I know you may not be considered primary. I mean, you are her primary insurance. You're her only insurance. Um, are you guys showing another insurance?
[AGENT][NEUTRAL] Mm, no, so here when we, um, how this, how we work is if we, being that we're not affiliated with any primary insurance, we can't.
[AGENT][NEUTRAL] Um.
[AGENT][NEUTRAL] 1
[AGENT][NEUTRAL] I'm trying to pull it up.
[AGENT][NEUTRAL] pull it up.
[AGENT][NEUTRAL] I'm gonna have to transfer you to the queue that actually process these claims because I don't process them. I could just read what's in the system about what's going on with the ELB with a claim status or the benefits.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] I just wanna make sure I like just build the patient.
[AGENT][NEUTRAL] OK hold one moment, OK? So let me transfer you.
[CUSTOMER][NEUTRAL] If they could even send me something that shows OK.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Referring.
[AGENT][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. May I help you?
[AGENT][POSITIVE] Hey [PII], how are you doing?
[CUSTOMER][POSITIVE] I'm good, yourself?
[AGENT][NEUTRAL] Oh, I'm OK, [PII]. I have no complaint. [PII], I have a provider on the phone. She's calling about a HI policy, a claim. I gave her the status of the claim. I told her that this policy only offers $50 per visit for office visits, but she says that our ELB does not is not explain, doesn't explain why it's not paying for procedures for a procedure code and it is not explanatory of.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Jesus.
[AGENT][NEUTRAL] Such and such and she wants to know why, and I told her that.
[AGENT][NEUTRAL] Literally says that the benefits were out and it's not covered under the policy, but she wants to know why our ELB is not like other ELBs that states that.
[CUSTOMER][NEUTRAL] Cause it's not covered under the policy?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Because we're not a company. [PII], I'm sorry.
[AGENT][NEUTRAL] And I told her that we're not a primary insurance company, so we can't tell her that. But I did let her know that if you submitted a bill for $983 and we only pay $50 that means there's a possibility that that balance is still owed to you. However, I can't tell you to charge the insured, but she wants to go.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] More and beyond, just out of my, I don't know what to tell her.
[CUSTOMER][NEUTRAL] Alright, tell her the same thing you did. Uh, give me one moment I'm just typing in this note is not covered.
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] I don't know why she just animate to.
[AGENT][NEGATIVE] Because I'm gonna get in trouble if I charge the insured and I'm not supposed to. I said, well, this is not a discounted policy. It's just a.
[CUSTOMER][NEUTRAL] Uh, should be fine.
[CUSTOMER][NEUTRAL] Right. What's that policy number?
[AGENT][NEUTRAL] 238848-8 for [PII].
[CUSTOMER][NEUTRAL] Say it one more time. 238848-8.
[AGENT][NEGATIVE] 48. Mhm. Every everybody keeps saying my phone is corny. Is it messed up that bad.
[CUSTOMER][MIXED] It's not horrible. It's just, uh, it's like the volume turns down and then turns up just a little bit.
[AGENT][NEUTRAL] And it's all the way up.
[CUSTOMER][NEUTRAL] That's all good. What's the name of the provider that's calling?
[AGENT][NEUTRAL] It's [PII] and the claim ended in 6722.
[CUSTOMER][NEUTRAL] And what's her name? You said [PII]?
[AGENT][NEUTRAL] Mhm. [PII]
[CUSTOMER][NEUTRAL] Just script probably.
[CUSTOMER][NEUTRAL] Uh, data service [PII].
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] This is just an indemnity plan.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Whatever, fella. Uh, you can send them to me and I'll explain to them.
[AGENT][POSITIVE] All [PII], [PII]. Well, thank you. Have a good day.
[CUSTOMER][NEUTRAL] We tracking.
[CUSTOMER][POSITIVE] You're welcome. You too have a great weekend.
[AGENT][POSITIVE] Thank you.
[AGENT][POSITIVE] Hello [PII], I'm gonna transfer you over to [PII]. She's gonna better assist you. Thanks for calling APL and you guys have a great day. Bye.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] OK, thank you.