AccountId: 011433970860
ContactId: 92f2e5cf-8e30-4731-b92a-29acd4ae6ff0
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 720049 ms
Total Talk Time (AGENT): 248538 ms
Total Talk Time (CUSTOMER): 324969 ms
Interruptions: 1
Overall Sentiment: AGENT=0.7, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2024/12/31/92f2e5cf-8e30-4731-b92a-29acd4ae6ff0_20241231T13:55_UTC.wav
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[AGENT][NEUTRAL] This is [PII].
[CUSTOMER][NEUTRAL] Hey [PII], it's [PII]. How are you today?
[AGENT][POSITIVE] I'm good. How are you doing, [PII]?
[CUSTOMER][NEGATIVE] Oh, well, I was thinking it might be a little slower today and less hectic than yesterday, but I think I was very wrong.
[AGENT][POSITIVE] Oh wow.
[CUSTOMER][NEUTRAL] At this point,
[CUSTOMER][POSITIVE] But I hope you're doing great.
[AGENT][POSITIVE] OK, thanks for the update.
[CUSTOMER][NEUTRAL] So I have
[CUSTOMER][NEUTRAL] Yeah, I have an insured on the line who um
[CUSTOMER][NEUTRAL] Has got more questions on this claim that we reviewed. I went over her remarks with her, but.
[CUSTOMER][NEUTRAL] Um, anyway, she needs more information because she's saying it's
[CUSTOMER][NEUTRAL] There's multiple dates of service on here for one.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, the policy number is 2463267 [PII]. She's fully verified and she did give me a different number than what's on file. This I believe is her work number that she gave to me today, 815.
[CUSTOMER][NEUTRAL] 282-758-1
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, and it's the only claim that's out there for her 354-582-2.
[AGENT][NEUTRAL] OK, I'm pulling it up. You can send her over.
[CUSTOMER][POSITIVE] All right. Well, thank you so very much. And should I not talk to you again today, which I probably will at this rate, I hope that you have a very happy [PII] Year.
[AGENT][NEUTRAL] You do the same, [PII].
[CUSTOMER][POSITIVE] Thank you, [PII]. OK, so just one moment. Now I'll release her to you.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Hello, um, hi [PII]. Is this, um, let's see, [PII]?
[CUSTOMER][NEUTRAL] Yes it is.
[AGENT][NEUTRAL] Um, hi, [PII]. This is [PII] in the claims department, and I'll further assist you um with your claim. One moment. I'm pulling it up now.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] Mm, no problem.
[AGENT][NEUTRAL] OK. Yes, ma'am. I have the claim pulled up. Now, what are your specific questions?
[CUSTOMER][NEUTRAL] Well they're saying that the primary paid full benefits, but I mean I still have a balance that I have to pay for this bill, so I don't quite understand. I mean.
[CUSTOMER][NEUTRAL] You know, I've got other bills. I mean this was my knee replacement surgery, so I don't quite understand.
[CUSTOMER][NEUTRAL] You know I've got bills from the doctor's office. I've got bills from the the um.
[CUSTOMER][NEUTRAL] What do you call it the anesthesiologist that you know so I'm just wondering, did I not submit everything that needed to be submitted.
[CUSTOMER][NEUTRAL] And then the other thing is is the date of service that's on the one that's processed here that's on.
[CUSTOMER][NEUTRAL] You know, [PII]
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I didn't have surgery that day. That day I went in.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] The instruments at the hospital did not get sterilized.
[CUSTOMER][NEUTRAL] So I never had surgery. I went home.
[CUSTOMER][NEGATIVE] Never they they told me at the the thing that the insurance my insurance company that I shouldn't even get a bill for that because nothing was done.
[AGENT][NEUTRAL] OK. Yes, ma'am. I'm showing that
[CUSTOMER][NEUTRAL] So my actual.
[CUSTOMER][NEUTRAL] My actual day of surgery was [PII].
[AGENT][NEUTRAL] Yeah,
[AGENT][NEUTRAL] OK. I do show um dates of services for [PII] for the surgery and I do show other dates of services also. And, just according to the documentation that we have, the EOB is not saying that your primary insurance company covered the charges in full. What the EOB is saying is that your primary insurance um did not cover the charges.
[AGENT][NEUTRAL] And if your primary insurance denies a charge, then um APL is your secondary insurance, we deny it also cause we only cover the portions that goes towards the copay, the co-insurance and deductibles. But if you have updated explanation of benefits that shows something different, that shows that they did cover part of these services and portions went to the co-pay, the co-insurance or deductible, you can resubmit those documentations and we can
[AGENT][NEUTRAL] Um, refile and have your claim paid. But according to what we have, cause that's all we can go by is what we have, um, according to this documentation, your primary insurance, um, denied these charges.
[CUSTOMER][NEUTRAL] And which ones were they did they deny?
[AGENT][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] This was for the hospital charges, um, date of service, [PII].
[AGENT][NEGATIVE] Well, according to the uh the EOB for those charges, those were paid in full. But then charges for date of service, um, [PII]. I'm showing that that denied.
[CUSTOMER][NEGATIVE] Yeah, I, I'm not even talking about the, I'm asking, I'm not even asking for 6 2024. I'm talking because that was.
[AGENT][NEUTRAL] OK. Well, you submitted it. If you submit something, we have to um acknowledge it and enter it into the system. OK.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Well, I only did what the explanation of benefits that that had maybe I submitted the wrong paperwork, um.
[CUSTOMER][NEUTRAL] Alright, I'll have to look and see what I because I've.
[CUSTOMER][NEUTRAL] Let me see here.
[AGENT][NEUTRAL] Yeah, we have dates of services [PII], dates of services [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so the hospital thing I've got on here is all 79 and 710. OK, so explanation of benefits.
[CUSTOMER][NEGATIVE] OK, 6:20, yeah, screw that 6:20 there it wasn't even supposed to be anything billed for that.
[CUSTOMER][NEUTRAL] Yeah, so I only have
[CUSTOMER][NEUTRAL] OK, so this is 6:20.
[CUSTOMER][NEUTRAL] That's 797979 and 10.
[CUSTOMER][NEUTRAL] 9 and 10.
[CUSTOMER][NEUTRAL] 9 and 10.
[AGENT][NEUTRAL] Yeah, and according to those particular charges for 79 and 170, it is showing that the primary um insurance carrier covered those in full. But like I said, if you have an updated EOB showing something different, you can resubmit the um explanation of benefits for those dates of services only and we can get this reprocessed and paid for you.
[CUSTOMER][NEUTRAL] 9
[CUSTOMER][NEUTRAL] What is not what is an EOB?
[AGENT][NEUTRAL] Um, the explanation of benefits, the, um, documentation, yeah, that you received from your primary insurance from UnitedHealthcare.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] And see, I, this is what I got what I wrote out from the explanation of benefits, but like I said, all this stuff from 620 is.
[CUSTOMER][NEUTRAL] I mean
[CUSTOMER][NEUTRAL] I don't know why they did put it on there because.
[CUSTOMER][NEUTRAL] If they paid that they're.
[CUSTOMER][NEGATIVE] He shouldn't have.
[CUSTOMER][NEUTRAL] Because I I have a claim on that as far as they told me the claim number so.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] So you're only interested in um reimbursement for 79 to 710?
[CUSTOMER][NEGATIVE] Yeah, because I mean 7620 like I said I shouldn't even gotten a bill for it. I called by the Questco people um and told me that no they shouldn't even have billed. I have a.
[CUSTOMER][NEUTRAL] I have a claim number as far as that that I talked to them about um on that because like I said it wasn't done now granted I have.
[CUSTOMER][NEGATIVE] I had other bills that I did not submit to you guys um from the doctor's office and the anesthesiologist is that something that I should have also um.
[CUSTOMER][NEUTRAL] You know, added in.
[AGENT][NEUTRAL] Well, you can submit that documentation, but we actually only go by what's on the explanation of benefits. So if you can um reach out to UnitedHealthcare and ask them for an updated explanation of benefits for the dates of services 7-9 through 7-10 and see if they can email you or.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mail you that documentation and once you receive it, um you can resubmit the claim, you can submit that information to us and write this claim number on there.
[AGENT][NEUTRAL] And let us know that that's the documentation that you're resubmitting so that that claim can be paid.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] And do you have the claim number?
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] Yeah, it's on my I'm on the website so it's 354-582-2.
[AGENT][NEUTRAL] Yes, ma'am. That's correct. And do you understand what you, what you need to do in order to get this paid?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, yeah, I need to get, I need to, um, call United Healthcare and get a new EOB and that, um, I can res and resubmit the claim.
[AGENT][NEUTRAL] Right, and you're
[CUSTOMER][NEUTRAL] And then um.
[CUSTOMER][NEUTRAL] Go ahead.
[AGENT][NEUTRAL] And you only need the explanation of benefits for dates of services [PII].
[AGENT][NEUTRAL] Unless there's other dates of services that you think need to be paid also.
[CUSTOMER][NEUTRAL] No, I don't think so um.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] All right, um.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I'll and then I'll submit the other stuff I mean it doesn't it's not gonna hurt if I submit it, you know, worst case scenario if you can just say no it's you know on that or if you might need something else correct?
[AGENT][NEUTRAL] Right. Yeah, if you resubmit the other documentation, it'll just be denied as a duplicate.
[CUSTOMER][NEUTRAL] OK, if I resubmit the other stuff that I already have because you already have that I don't need to resubmit anything else, OK.
[AGENT][POSITIVE] That's correct.
[AGENT][NEUTRAL] Right.
[CUSTOMER][POSITIVE] All right, OK, alright, perfect.
[AGENT][NEUTRAL] Yeah, and just make sure you write and when you get the um explanation of benefits for United Healthcare, from United Healthcare, make sure that you write the claim number on there. So we'll know that that's the documentation you're resubmitting for that claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Is there anything else that I can assist you with?
[CUSTOMER][NEUTRAL] Alright.
[CUSTOMER][NEUTRAL] No I don't think so thank you very much I appreciate it you have a great day.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] You do the same, [PII]. Thank you for calling ATL. Mm bye.
[CUSTOMER][NEUTRAL] Alright
[CUSTOMER][POSITIVE] Alrighty thanks bye bye.