AccountId: 011433970860
ContactId: 83cc26e3-be8c-427c-aeee-3d871c67d421
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 471790 ms
Total Talk Time (AGENT): 150194 ms
Total Talk Time (CUSTOMER): 103228 ms
Interruptions: 0
Overall Sentiment: AGENT=0.9, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/20/83cc26e3-be8c-427c-aeee-3d871c67d421_20250520T21:01_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Uh, hi, my name is [PII]. I'm with Marshall Chiropractic Life Center in [PII]. We have a patient, uh, [PII]. Um, according to his benefits, he gets 4 chiropractic visits a year, um, and we received payment from you guys of $150 for his, uh, date of service [PII], but I received a letter in the mail today asking for that back saying that.
[CUSTOMER][NEGATIVE] We're not a qualified physician to uh let me qualified physician to practice medicine and so I I don't understand why it's being asked for back.
[AGENT][NEUTRAL] OK. Well, I can help you with your claim. And [PII], may I have a good contact number in case we're disconnected and the member's policy number?
[CUSTOMER][NEUTRAL] [PII]. His policy number is 023488888.
[AGENT][NEUTRAL] OK, can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] [PII], uh, [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.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] And what is the claim number that you have?
[CUSTOMER][NEUTRAL] 356-679-2.
[AGENT][NEUTRAL] Here it is, OK.
[AGENT][NEUTRAL] Alright, is it OK if I place you on just a brief hold so I can look at the claim?
[CUSTOMER][NEUTRAL] That's fine.
[AGENT][NEUTRAL] Alright, hold on one moment.
[CUSTOMER][NEUTRAL] Thank you. You are on hold.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] All right, what
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] That's a different claim.
[AGENT][NEUTRAL] qualified
[AGENT][NEUTRAL] OK, wait a minute. First of all, it's possible indemnity. What type of chiropractic benefit does it have?
[AGENT][NEUTRAL] Let's start there.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Hello, [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Alright, thank you so much for holding. I apologize for that wait. So what I'm gonna do um is get a cus um a claims examiner on the line to go over this more in detail with you. From what I see, um, I pulled up the benefits and I don't see that chiropractor is covered. So it looks like that first claim, um, 6 or 356-6792 should not have been paid because chiropractic care isn't covered. This is a limited medical policy, um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] But I'm gonna get an examiner on the line just to go over it more and to let you know of next steps and to see if if what I because I just want to be sure.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] You're very welcome. Before I do that, was there anything else I could assist you with today?
[CUSTOMER][POSITIVE] That'll be it thank you.
[AGENT][NEUTRAL] You're welcome. Thanks for calling APL. Hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][NEUTRAL] Afternoon, thanks for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hey [PII], this is [PII] on the care team. How are you doing?
[CUSTOMER][POSITIVE] I'm good. How are you?
[AGENT][NEUTRAL] I'm doing good. Um, I have a provider on the other line. They received a payment from us and then later a letter requesting it back saying that their provider isn't a physician, it's a chiropractor. Um, can I give you the policy number?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It's 234.
[AGENT][NEUTRAL] 8888.
[AGENT][NEUTRAL] The original claim is the 356-679-2. This is for part two.
[AGENT][NEUTRAL] And then the one where we ask for it back is ending in 8222.
[CUSTOMER][NEGATIVE] And we mailed a letter asking them to to send a refund to us.
[AGENT][NEUTRAL] It looks like it was on the EOB because I pulled up the remark code and it said what she said, but she said it was a letter.
[CUSTOMER][NEUTRAL] Give me one second to pull up the EOB.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, let's see.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The refund request letter is under 8199 OK.
[CUSTOMER][NEUTRAL] And what is she wanting? What is, what is her question?
[AGENT][NEUTRAL] So they wanted to know why was it, um, why are we asking for the refund and how are we determining that their doc their physician isn't a physician?
[CUSTOMER][NEUTRAL] OK, you can send her on over.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] Hello [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Thank you so much for holding. I have [PII] on the line and she'll be assisting you further, OK?
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You're welcome.