AccountId: 011433970860
ContactId: a15da815-d4c8-4e32-987c-0594da46502a
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 526960 ms
Total Talk Time (AGENT): 302663 ms
Total Talk Time (CUSTOMER): 187653 ms
Interruptions: 2
Overall Sentiment: AGENT=0.1, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/28/a15da815-d4c8-4e32-987c-0594da46502a_20250528T20:29_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], it's [PII]. I have an insured on the phone. Her name is [PII].
[CUSTOMER][NEUTRAL] Her policy number is 2572507.
[CUSTOMER][NEUTRAL] She called a little bit spicy because she received the letter stating that her claim was a duplicate and that we had asked her to send in the explanation of benefits and itemized statement and she did that.
[CUSTOMER][NEUTRAL] But she also sent in the whole rest of the claim, so I explained to her that's why it was duplicated because we only needed the information that was requested to finish the original claim.
[CUSTOMER][NEUTRAL] She asked me how come we need the itemized statement? Isn't the explanation of benefits good enough? I told her that the itemized statement has the diagnosis and procedure because it comes from the facility and we have to have that. She wants to argue about that because she's been doing insurance for 8 years for her company.
[AGENT][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] And she just wants
[CUSTOMER][NEUTRAL] Wants a better to talk to somebody in in the claims specialist department so that we can go over how we process our clients.
[AGENT][NEUTRAL] Oh Jesus, OK, so what's which.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I'm assuming she's talking about the 1781, correct? Claim ending in 1781.
[CUSTOMER][NEUTRAL] Yeah, the 17
[CUSTOMER][NEUTRAL] Yes, and then the um the 3,605,020 was the duplicated claim.
[AGENT][NEUTRAL] Yeah, OK.
[AGENT][NEUTRAL] I'm pulling up the mail number so I gotta pull up separately so I'm sorry and she's been verified, sorry?
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] Yes. That's OK.
[CUSTOMER][POSITIVE] Yes, she has been verified, yes ma'am.
[AGENT][NEUTRAL] And that's her phone number?
[AGENT][NEUTRAL] It's [PII], right?
[CUSTOMER][NEUTRAL] Yes, her phone number is the, yes, and that's the number she's calling from is her call back.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Is it Picone or peone?
[CUSTOMER][NEUTRAL] Alright, I'm gonna let you have her.
[AGENT][NEUTRAL] You know?
[CUSTOMER][NEUTRAL] It's, um,
[CUSTOMER][NEUTRAL] Pecan, pecan.
[AGENT][NEUTRAL] Pecan, OK.
[CUSTOMER][NEUTRAL] Because I thought she said peone and it's pecone.
[AGENT][NEUTRAL] OK, got it.
[CUSTOMER][NEUTRAL] OK, I just just calling her Miss [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. Thanks, [PII]. Mm bye-bye.
[AGENT][POSITIVE] Thanks, [PII]. Bye.
[CUSTOMER][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Hello Miss [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Hi, my name is [PII]. I'm on the claim support team and [PII] transferred you over to me so we can get some further clarification on what's needed for your claim.
[AGENT][NEUTRAL] Um, I understand you had some questions about the requirement.
[CUSTOMER][POSITIVE] Yeah, OK, thank you.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so it looks like we received it.
[CUSTOMER][NEUTRAL] Well, I sent in all the documents. Yeah, I wanna understand why it's not getting paid. I believe I have everything sent to you.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK, so what I did was pull up that previous information that was sent in to us and it looks like we received the explanation of benefits from your primary insurance, the United Healthcare.
[AGENT][NEUTRAL] And it looks uh.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] We have the procedure codes, the data service. We have the amount um that was uh oh you know allowed under your plan and what was paid and then it does show up the amount you owe for coins I'm assuming it's co-insurance because there's not a um.
[CUSTOMER][NEUTRAL] It's deductible. Yeah, deductible.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I do see that applied to deductible. OK, I'm sorry about that, yes, OK, so, um, what is needed is normally um when we receive these claims for the um for this uh product that you have the Medlink plan, um we do require that billing to accompany that explanation of benefits from the primary insurance.
[CUSTOMER][NEUTRAL] Um, uh-huh.
[AGENT][NEUTRAL] So this plan does, you know, it, it, it will pay for your co-insurance and or deductible uh for services covered under the plan up to your maximum amount. However, we do have to have the um procedure and diagnosis codes to
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Uh, go along with your explanation of benefits but sometimes they don't offer enough detail, um, on the explanation of benefits from, from the primary insurance. So it looks like we're missing the diagnosis codes um for the.
[CUSTOMER][NEUTRAL] So I sent you I sent you the state the itemized statements from Envision. Can you take a look at that? Like what's the deal there?
[AGENT][NEUTRAL] Yes, I'm looking at that now.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, and again it gives us that description, but it doesn't give us that diagnosis code, so it does give us those procedure codes but not the diagnosis code. So normally, um, can I ask you, Ms. [PII], do you, uh, give your both of these insurances to your provider, um, at the time of service, or you're only providing them that United Healthcare information?
[CUSTOMER][NEUTRAL] So I'm, I'm filing these on my own.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] I've already paid it. I've already paid them.
[AGENT][NEUTRAL] Got you. OK, so normally, um, so, so that there's not, so you're not inconvenienced by requesting this additional information like I said normally those claims are sent in by that provider of service.
[AGENT][NEUTRAL] Um, you know, whether it be the laboratory or, um, you know, the physician's office or hospital, normally they'll send us that information and they provide that billing information along with the explanation of benefits showing your coinsurance and or deductible amounts that are due. So, um, in the event that you are filing the claim yourself, however, we would still require that same information.
[AGENT][NEUTRAL] Um, so we do require that itemized bill with procedure and diagnosis codes along with that explanation of benefits from the primary insurance.
[CUSTOMER][NEUTRAL] So when I asked envision for the itemized this billing, this is what they sent me.
[CUSTOMER][NEUTRAL] Doesn't that violate HIPAA by like giving a billing company like your diagnosis code?
[AGENT][NEUTRAL] Well again that's what the if you were presenting this card with it, you know, you assign that benefit over to that provider, you know, and.
[CUSTOMER][NEUTRAL] Whether I'm not, you didn't answer my question, just answer my question.
[AGENT][NEUTRAL] I don't believe so, no, not when it's in the course of doing business. If we have to require this information to process your claim, then no, it would not. Um, the the billing service has that information. They should have that information. They sent the claim to your primary insurance, and the primary insurance requires the same information.
[AGENT][NEUTRAL] So that information is already envision already has that information if they bill to United Healthcare, then they would have that information from the physician or whoever provided.
[CUSTOMER][NEGATIVE] OK, look, you're not hearing me, honey, I've already paid these.
[AGENT][NEUTRAL] Yes ma'am, I understand that I.
[CUSTOMER][NEGATIVE] Help me figure out how to freaking get paid here, my gosh. I wish customer service is dead these days. I'm telling you.
[AGENT][NEUTRAL] Well, I mean, I apologize for any inconvenience for you. However, like I said, we do require that procedure in fact.
[CUSTOMER][NEUTRAL] Can I write in, can I write in for you, can I write in for you the diagnosis code? Cause I have it on the order. I have an order to get the ultrasound of my breast. Do you want me to just give you that? Cause I've got that.
[AGENT][NEUTRAL] We can't accept it handwritten or verbal. It would need to be provided to us if you have that information, you can submit that information along with your claim or you can call the facility like the Labor facility. We don't have a diagnosis code and additionally there is no procedure codes as well on the Labor bill. There's just a description of the services they provided, you know, and, and but they don't have this.
[CUSTOMER][NEUTRAL] Oh my God.