AccountId: 011433970860
ContactId: a472419d-7f90-48e0-8a56-03afb88020f8
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 668760 ms
Total Talk Time (AGENT): 144512 ms
Total Talk Time (CUSTOMER): 269014 ms
Interruptions: 1
Overall Sentiment: AGENT=0.1, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/07/a472419d-7f90-48e0-8a56-03afb88020f8_20250207T20:35_UTC.wav
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[AGENT][NEUTRAL] This is [PII]. May I help you?
[CUSTOMER][NEUTRAL] Hey [PII], this is [PII] over on the care team. How are you?
[AGENT][NEUTRAL] I'm fine. How are you?
[CUSTOMER][NEUTRAL] Doing all right thank you. I have a provider on the line calling regarding a claim um and he said that he believes that we overpaid on it and wanted to take a look at that. I believe it was processed by um [PII], but I did try to call her. I don't think she's available um is that something you could look at or should I just try reaching out to her?
[AGENT][POSITIVE] I can help him with it and pass it on, yeah.
[CUSTOMER][NEUTRAL] OK, sure, I appreciate it, um, the policy number is 02365891.
[AGENT][NEUTRAL] And what's his name?
[CUSTOMER][NEUTRAL] Oh, his name is [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And uh does he have a callback number?
[CUSTOMER][NEUTRAL] Yes, it is [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And I've got that claim number too.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It is 354-819-3.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Are you ready to speak with him?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] All right, I appreciate your help, [PII]. Thank you, bye bye.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] This is [PII]. May I help you?
[CUSTOMER][NEUTRAL] Uh, hi, [PII]. This is [PII]. Uh, I got transferred from your, one of your representatives, [PII].
[AGENT][NEUTRAL] OK, how can I help you?
[CUSTOMER][NEUTRAL] I'm checking regarding a claim.
[AGENT][NEUTRAL] For 12:19?
[CUSTOMER][NEUTRAL] Yeah, 12:19.
[AGENT][NEUTRAL] OK, and.
[AGENT][NEUTRAL] What's the question on the claim?
[CUSTOMER][NEUTRAL] Uh, actually, regard, um, checking regarding the, uh, fees, uh, as per our, uh, record, the claim is, uh, paid, uh, like overpaid as per the fees.
[AGENT][NEUTRAL] OK. Why, how do you think it's overpaid?
[CUSTOMER][NEGATIVE] Uh, we are expected less than which we received. Uh, we received like $301.60 but we are, you know, expecting less than that.
[CUSTOMER][NEUTRAL] So I just want to confirm from your side was it processed correct.
[AGENT][NEUTRAL] OK, why was it?
[AGENT][NEUTRAL] Why were you expecting less?
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Because, uh, cleaning processes.
[CUSTOMER][NEUTRAL] Because for in-network she processes that network.
[AGENT][NEGATIVE] This policy doesn't have a network.
[CUSTOMER][NEUTRAL] So for in-network or out of network, the fees will be the same?
[AGENT][NEUTRAL] Right, there's no network for this policy.
[CUSTOMER][NEUTRAL] Uh, there is no.
[AGENT][NEUTRAL] The charge was 391.
[AGENT][NEUTRAL] The UCR was 377, so it'd be 377 times.
[CUSTOMER][NEUTRAL] This policy.
[AGENT][NEUTRAL] 40%.
[CUSTOMER][NEUTRAL] OK, so the charge amount is 391 and this year is 377 and you paid 40% of that, right?
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So the uh claim.
[AGENT][NEUTRAL] Which equals 150 80, it was paid correct.
[CUSTOMER][NEUTRAL] Correctly, OK. Now, I just want to confirm from your side it correctly. So there is no network for this uh policy, uh, in-network and out of network uh will be paying the same fees for both.
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] Right.
[CUSTOMER][POSITIVE] Perfect, uh.
[CUSTOMER][NEUTRAL] Can you, uh, can you help me with the, a reference number on this number?
[AGENT][NEUTRAL] We do not have reference numbers. You can use my name and today's date.
[CUSTOMER][NEUTRAL] OK. Your name is [PII]?
[AGENT][NEUTRAL] [PII]
[CUSTOMER][POSITIVE] Perfect. Uh, is it possible for you to check one more claim for today?
[AGENT][NEUTRAL] Hold on one moment. I'll have to get this in before I move to another one.
[CUSTOMER][NEUTRAL] For different members.
[AGENT][NEUTRAL] Is it on the same member or a different member?
[CUSTOMER][NEUTRAL] Other different member?
[AGENT][NEUTRAL] OK, hold on.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] We
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] What's the next policy number?
[CUSTOMER][NEUTRAL] 3
[CUSTOMER][NEUTRAL] Next policy number I have.
[CUSTOMER][NEUTRAL] 02277598
[AGENT][NEUTRAL] Pa's name.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Data service.
[CUSTOMER][NEUTRAL] Date of birth is December date of service.
[AGENT][NEUTRAL] I mean, date of birth, I'm sorry.
[CUSTOMER][NEUTRAL] Date of birth is [PII].
[AGENT][NEUTRAL] Data service.
[CUSTOMER][NEUTRAL] 16 of 25.
[CUSTOMER][NEUTRAL] 790 is the total submitted amount.
[AGENT][NEUTRAL] OK. And what do you need to know about this claim?
[CUSTOMER][NEUTRAL] Uh, actually, uh, for that, you'll be, uh,
[CUSTOMER][NEUTRAL] No
[CUSTOMER][NEUTRAL] Some of the code was not paid, so I need to check if it's
[CUSTOMER][NEUTRAL] Not covered or like what was the reason on that?
[AGENT][NEUTRAL] The 22021.
[AGENT][NEGATIVE] It went to the deductible so nothing was paid.
[AGENT][NEUTRAL] 1330 is not covered by the policy.
[AGENT][NEUTRAL] 01206 is not covered by the policy.
[AGENT][NEUTRAL] 1120, we paid $92.
[AGENT][NEUTRAL] And 00274 is only payable once in 12 months.
[CUSTOMER][NEUTRAL] D 112094 frequency.
[AGENT][NEUTRAL] Hold on just a moment. I'm sorry. Hold on one moment.
[AGENT][NEUTRAL] Let me see what this is.
[AGENT][NEGATIVE] I don't know why she did it.
[CUSTOMER][NEUTRAL] The
[CUSTOMER][NEUTRAL] For you
[CUSTOMER][NEUTRAL] We
[AGENT][NEUTRAL] Yes, the 274 is only payable once in 12 months, so.
[AGENT][NEUTRAL] They had already have had one.
[CUSTOMER][NEUTRAL] OK, so, uh, what was the last history, uh, for the.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] 2 21 24.
[CUSTOMER][POSITIVE] Perfect.
[CUSTOMER][NEUTRAL] The same provider, uh, with the same uh provider for 221 I have like a provider name is [PII] or is different provider.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Hold on, I have to look.
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] 17
[AGENT][NEUTRAL] What did you say the provider's name was?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] I do not see that name.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][POSITIVE] OK perfect so different.
[CUSTOMER][NEUTRAL] And for the, uh, as you said, the procedure D 0220, uh, this code.
[CUSTOMER][NEUTRAL] Payment applied to the patient deductible for $40. So, uh, what is the annual deductible? Is it $50?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] So, OK, so the patient members still have the uh $10 remaining right to satisfy?
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] Yes, $10.
[CUSTOMER][POSITIVE] Perfect. And for the fluoride, uh, was it a non-covered service or for denied for age restriction or denied age limit?
[AGENT][NEGATIVE] Non-covered service.
[CUSTOMER][NEGATIVE] Non-covered service.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] 123.
[CUSTOMER][NEUTRAL] And 1330 is also non-covered service, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Did you pay for claiming D1120?
[AGENT][NEUTRAL] Yes, I told you we pay $92.
[CUSTOMER][POSITIVE] 92. And for D 0120 $75. Perfect.
[CUSTOMER][NEUTRAL] I've got all this information. I'll just, OK.
[CUSTOMER][POSITIVE] Perfect. And the reference number will be the same, right? It's uh your name and the state.
[AGENT][NEUTRAL] Right. Mhm.
[CUSTOMER][POSITIVE] Perfect. This is the only information looking, so thank you so much for your patience and help. I hope you have a lovely weekend.
[AGENT][POSITIVE] Thank you, [PII] for calling APL. You as well.
[CUSTOMER][POSITIVE] Thanks you too bye bye.