AccountId: 011433970860
ContactId: 8ff67d67-7c1b-451f-94fd-77ceeb987c60
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 274109 ms
Total Talk Time (AGENT): 104640 ms
Total Talk Time (CUSTOMER): 158842 ms
Interruptions: 1
Overall Sentiment: AGENT=0.6, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/30/8ff67d67-7c1b-451f-94fd-77ceeb987c60_20250430T13:05_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey, [PII], it's [PII]. Good morning. How are you?
[AGENT][NEUTRAL] Fine, how are you?
[CUSTOMER][NEUTRAL] I'm good, I guess, um, so look, the reason I'm transferring, can I go ahead first off, I guess I just need to give you the policy number, don't I? Mhm.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] 174-0278.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yes ma'am. OK, so the claim number is 3592981.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so I have a provider on the line. Her name is [PII]
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] She said that she had been emailing regarding this claim and that even [PII] has called her about this claim. Now there's not any notes about any of that in here, but that's too much information for me to believe that it's not true.
[CUSTOMER][NEUTRAL] And she was given the claim status given the the paid amount.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] But the provider filed a claim in the portal and it shows a P in the portal.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] But this indicates that we issued payment to the insured.
[AGENT][NEUTRAL] OK, let me look, let me pull it up.
[CUSTOMER][NEUTRAL] So she was calling back this morning because she can't access the EOB in the online service center. Well, that's because there's not a provider EOB in the portal.
[AGENT][NEUTRAL] It's not, it was submitted by the provider. I'm looking at the form cause I really can't see. There's an X cause normally if we get, if it does not have an assignment of benefits, then we issue it to the insured. But the way this CMS form is up but there's an X but I don't know what box it fall in cause normally those are boxes there in that box, those boxes would say if it's a sign of benefit or not, but I guess the way they're.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] CMS, it didn't pull over properly on their CMS form.
[AGENT][NEGATIVE] Uh, but yes, it definitely is a provider claim and it should have been paid to the provider because it was a provider claim. Let me look at something else real quick.
[CUSTOMER][NEUTRAL] So that's why I didn't create a ticket to have a call back, yeah, for research because she's already been given.
[AGENT][NEUTRAL] I don't know if the examiner reached.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] The amount paid.
[AGENT][NEUTRAL] OK, let's see here.
[CUSTOMER][NEUTRAL] and all of that.
[CUSTOMER][NEUTRAL] So I went ahead and told her this may have been wrong [PII], but I went ahead and told her that the reason that she cannot see it is because it appears that the benefits were paid to the member.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] I mean, I did tell her that because she already had the amount I mean everything.
[AGENT][NEUTRAL] I wanna, I'm trying to see if, no.
[CUSTOMER][NEUTRAL] She was just trying to get an EOB.
[AGENT][NEUTRAL] I was trying to see if there's any notes that the examiner had reached out to them to verify. Uh, I don't.
[CUSTOMER][NEUTRAL] Nope. There is nothing of that. Nope.
[AGENT][NEUTRAL] No
[CUSTOMER][NEUTRAL] Sure it's not.
[AGENT][NEUTRAL] Yeah, that claim, yeah, it should have been issued to the provider. That examiner have to reprocess that claim.
[AGENT][NEUTRAL] We process that claim to the provider.
[CUSTOMER][NEUTRAL] OK. And what, request a refund from the insured?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yup.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, so can you, I mean, do you want to talk to her and explain that, or do you want me to just tell her like I said, because she had been given so much information that she should.
[CUSTOMER][NEUTRAL] Have ban
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] I, I don't kind of know, I really don't know what to do with this one.
[AGENT][NEUTRAL] Yeah, I would just advise her that it, it appears that the benefit was issued to the member versus to the, to them that we'll have to send a request to have it reprocessed.
[CUSTOMER][NEUTRAL] I just
[CUSTOMER][NEUTRAL] OK, and will you do that or do I need to send a hub ticket?
[AGENT][NEUTRAL] If you'll send a hub ticket.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][POSITIVE] OK. All right. I will certainly be happy to do that and I appreciate you looking at, looking at it for me. And I'm not gonna release her to you. I'm just gonna tell her that.
[AGENT][POSITIVE] You, you're welcome.
[AGENT][POSITIVE] OK, thanks.
[CUSTOMER][NEUTRAL] OK, [PII], thank you. All right, bye-bye. All right, bye-bye.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Bye.