AccountId: 011433970860
ContactId: a666b51b-6898-4dad-a66c-8e70fa792acb
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 931780 ms
Total Talk Time (AGENT): 369321 ms
Total Talk Time (CUSTOMER): 412603 ms
Interruptions: 6
Overall Sentiment: AGENT=0.3, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/12/a666b51b-6898-4dad-a66c-8e70fa792acb_20250512T18:54_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] Hi [PII], my name is [PII] and I'm calling from South Miami Pain Center.
[CUSTOMER][NEUTRAL] I'm calling in reference to a payment that I received.
[CUSTOMER][NEUTRAL] Did you want the member ID or?
[AGENT][NEUTRAL] Um, well, 1st may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Uh yes, it's [PII].
[AGENT][NEUTRAL] Thank you for that. You said it's in reference to a payment that you received?
[CUSTOMER][NEUTRAL] Yes, uh, a partial payment.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And may I have, well, are you the provider or you're calling with the, you're the insured? OK. May I have the member's policy number?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] And the provider, provider, provider.
[CUSTOMER][NEUTRAL] It's 959-266-336.
[AGENT][NEUTRAL] Is that their social?
[AGENT][NEUTRAL] Maybe
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] I don't have uh let let me probably let me give you this one.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][NEUTRAL] OK, yes, that's the one.
[CUSTOMER][NEUTRAL] I was giving you the identification number from the OB that I received. I'm sorry.
[AGENT][NEUTRAL] Oh, it's OK. And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] It's [PII], yes, uh [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service or the claim number um for the claim you're calling in reference to?
[CUSTOMER][NEUTRAL] OK, the claim number that I have here is EX 60858636. And they have some other numbers. I don't know if I have to give it to you.
[AGENT][NEUTRAL] OK, so that may be the primary um claim number. Do you have anything from APL? It usually starts with like a 3.
[CUSTOMER][NEUTRAL] after that is 0552374478. I don't know if that's the claim number you're looking for.
[AGENT][NEUTRAL] What's the data service?
[CUSTOMER][NEUTRAL] OK. [PII].
[CUSTOMER][NEUTRAL] Oh, I'm so sorry. I was looking at the primary claim sorry I can't give you the claim number, hold on, mm.
[CUSTOMER][NEUTRAL] Let me see. OK. 357-475-7. Sorry.
[AGENT][NEUTRAL] It's OK.
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so we paid for this claim $277.27.
[CUSTOMER][NEUTRAL] Yeah, that's, yes, that's my question. Um, if you have the original EOB of the primary insurance, uh, usually, uh, United, um,
[CUSTOMER][NEUTRAL] You know this, the code 64493 and 64494 they pay in two different lines because it's billed bilateral. You only pay one of the lines so I don't know if the difference has to be transferred to the page or you pay for that.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] But you missed the uh.
[AGENT][NEUTRAL] No, we've
[AGENT][NEUTRAL] We paid for, paid for all three codes. 64493 was billed at $1182.52 and we paid that. 64494 was billed $94.31 and we paid that. J11.
[CUSTOMER][NEUTRAL] The breakdown.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] I'm sorry, go ahead.
[CUSTOMER][NEUTRAL] No, no, go ahead.
[AGENT][NEUTRAL] J1100 was charged 44 cents and we paid that, which is the total of the 27727.
[CUSTOMER][NEUTRAL] OK, but the the uh 64493, the uh primary Insurance United paid 18252 and 9126. When there is uh a modifier 50, they.
[CUSTOMER][NEUTRAL] I break it down in two lines.
[CUSTOMER][NEUTRAL] I can send you the um the original EOB.
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] If you, I, I'll send it with the, the original claim. If you can look at it.
[AGENT][NEUTRAL] Hold on one moment. Let me pull up the documents. Just give me one second.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Yes, sure.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I'm just waiting for them to come up. Hold on one moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, so the 64493 and the 64494.
[AGENT][NEUTRAL] Uh, I do see the 50 modifiers. So, so,
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] You only paid us unilateral the 182 52 for the 6493, but there is the 50% is 9126. Did you see the uh I sent the uh original EOB.
[CUSTOMER][NEUTRAL] Do you have it? The air from Medicare Complete ARP?
[AGENT][NEUTRAL] So you're saying even though it was billed for the modifier 50 since on the explanation of benefits, it shows the modifier 50 and the regular, we should do both?
[CUSTOMER][NEUTRAL] What some some United, what they do is they break down the modifier 50.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The 100% and then the 50% in another line.
[CUSTOMER][NEUTRAL] If you can see it, uh, you, do you have the original UB, the, the Medicare UB?
[AGENT][NEUTRAL] I have the remittance that was submitted, yes.
[CUSTOMER][NEUTRAL] OK. If you see, it says 6 or 49,450, 6 are 49,350, 6 or 493, and 6 are 494.
[CUSTOMER][NEUTRAL] If you go to 6 or 49,350, they allowed 18252 and 644939125.
[CUSTOMER][NEUTRAL] Instead of combining the uh the payment they do separate.
[AGENT][NEUTRAL] OK, um, so if you like, I can send this back to be reprocessed.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Yeah, and the 64494 is 9431, and then 64494 4716. It it's very confusing, but
[CUSTOMER][NEUTRAL] They do that, so what can I tell you?
[AGENT][NEUTRAL] So even though it was adjusted, they still are billing the patient for patient responsibility even though it wasn't billed and it was adjusted.
[CUSTOMER][NEUTRAL] OK, if you, if you, if you want it, no, that.
[CUSTOMER][NEUTRAL] What they should pay for 64493 with modifier 50 is, give me just a second.
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] It's 27,380, but they're doing two lines. The first line at 100% and the second line at 50 instead of combining both at 150.
[AGENT][NEUTRAL] I understand what you're saying. I just, because it wasn't because under bill it has zero, so that means that those two codes weren't billed.
[CUSTOMER][NEUTRAL] OK, but the patient responsibility, OK, let me add this.
[CUSTOMER][NEUTRAL] That's the line that it says member responsibility.
[CUSTOMER][NEUTRAL] 9126.
[AGENT][NEUTRAL] But if they didn't bill it and primary didn't apply to it, then secondary can't, which is why we did it. Primary adjusted that.
[CUSTOMER][NEUTRAL] 4716.
[CUSTOMER][NEUTRAL] Yes, we did. OK.
[CUSTOMER][NEUTRAL] No, look at the patient's responsibility in the primary UOB and it says.
[AGENT][NEUTRAL] So let's do this. Let's do this. Hold on one moment. What I'm gonna do is get a claims examiner on the line for you and y'all can discuss this further as to why they processed the claim the way they did. And then if it needs to be reprocessed, they can put it.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Yes, it's gonna be like that for all United, uh-huh. So United, yes.
[AGENT][NEUTRAL] Alright, so hold on one moment while I get a.
[CUSTOMER][NEUTRAL] If the patient has another procedure, it's gonna be like that too.
[AGENT][POSITIVE] Right, but I'm not in claims, so I'm gonna get you to claim so that they can fix this issue, so you don't have to do this moving forward.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] OK, I know I know because this is so confusing.
[AGENT][NEUTRAL] Alright, hold on one moment. Let me get a claims rep for you, OK?
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] All right.
[AGENT][NEUTRAL] All right, and before I do that, did you have any other questions or anything else I could assist you with today, [PII]?
[CUSTOMER][POSITIVE] No, no, that's it. That's it. Thank you, [PII].
[AGENT][NEUTRAL] Alright, hold on one moment. You're welcome. Thanks for calling APL.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEGATIVE] I'm not going back and forth. I don't understand.
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How can I help you?
[AGENT][NEUTRAL] Hey, [PII], this is [PII] on the care team. How are you doing?
[CUSTOMER][POSITIVE] Doing well [PII] thank you how are you?
[AGENT][NEUTRAL] I'm doing good. Um, I have a provider on the other line, um, that wants to speak to somebody. Can you look at this, uh, claim?
[CUSTOMER][NEUTRAL] Certainly.
[AGENT][NEUTRAL] It is policy number 1887382.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And it's part 2.
[CUSTOMER][NEUTRAL] For [PII].
[AGENT][NEUTRAL] Yes, and it's um claim number 357-4757?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so,
[CUSTOMER][NEUTRAL] 4757 let me pull up that document. OK, go ahead.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So she first called, this is the provider, first call saying that we didn't pay out to everything and I said, well, of the three cos we paid what was billed.
[AGENT][NEUTRAL] And then, um, I said that's what gave the total of the 277. She said, well, when there's a modifier, United Healthcare doesn't break it down or breaks it down, and we only paid half. So when I pulled it up in our base, I'm like, OK, well I see what you're saying, but for the ones that don't have a modifier, they weren't billed.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So, like there's no charge there. She said, but it still has a patient responsibility.
[AGENT][NEUTRAL] So,
[AGENT][NEUTRAL] When primary, if it's not built and primary didn't apply anything, they adjusted it, we're not going to apply anything, right?
[AGENT][NEUTRAL] Because we paid for the ones that were billed.
[AGENT][NEUTRAL] And we
[AGENT][NEUTRAL] We paid the allowed amount.
[CUSTOMER][NEUTRAL] Right, that's the way it looks to me is.
[CUSTOMER][NEUTRAL] So they're saying that.
[AGENT][NEUTRAL] She's saying, you see how that sick the.
[CUSTOMER][NEUTRAL] Yeah, I mean it has to, it, it has to match what's on the, the, the claim form has to match what's on the, you know, the EOB remittance advice, so um.
[AGENT][NEUTRAL] You'll be
[AGENT][NEUTRAL] Right, so I said, so are you saying because I said, so are you saying because the EOB shows the modifier and without the modifier that we should have paid without the modifier, even though we were only billed those three and she said, yeah, and I said, well, I don't know.
[AGENT][NEUTRAL] Wait a minute, because that, we are from what it looks like to me, we paid what we were billed.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right, and it looks like to me also that that allowed amount was also adjusted off.
[AGENT][NEUTRAL] Adjust it, right, and that's what I told her.
[CUSTOMER][NEUTRAL] Even though it shows, even though it shows on the patient responsibility, that's not the way this EOB reflects.
[AGENT][NEUTRAL] Mhm. And it doesn't match the claim form anyway.
[CUSTOMER][NEUTRAL] So,
[AGENT][POSITIVE] OK, so at least I read it right.
[CUSTOMER][NEUTRAL] Right, so we would have to.
[CUSTOMER][NEUTRAL] Yeah, I mean, if you want I'll speak to them and try to explain it.
[AGENT][NEUTRAL] Oh yes, because she's
[CUSTOMER][NEUTRAL] Since they wanna talk to somebody else. Mhm.
[AGENT][NEUTRAL] Yeah she's like, no, that's not how this works. You have to pay the patient responsibility and I'm like, but we weren't billed for that.
[AGENT][NEUTRAL] So, OK.
[AGENT][NEUTRAL] We, I just want to, but for me, for future, I did read that right correctly, I mean, right, because we paid.
[CUSTOMER][NEUTRAL] Yes, I mean
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right, yeah, I mean, as far as I can tell, yeah, no, because like I said those billed amounts are zero, and even though there's an allowed amount, it looks like those amounts were adjusted off and then they show it under patient responsibility. However, it doesn't reflect that on the bill claim line so.
[AGENT][NEUTRAL] So I started questioning myself.
[AGENT][NEUTRAL] We adjusted
[AGENT][NEUTRAL] Right, OK.
[AGENT][NEUTRAL] Well, you made that crystal clear for me. I just want to make sure cause I'm like, well, maybe, I'm like, OK, well, I'm not in claims, so maybe I don't, she knows something I don't know then.
[CUSTOMER][NEUTRAL] I don't know why.
[CUSTOMER][NEGATIVE] Yeah, I mean it's a it's kind of a messed up.
[CUSTOMER][NEUTRAL] I, I don't know why.
[CUSTOMER][NEGATIVE] I mean they, they can't, I would, I would assume that all these EOBs are not like this because they would never get paid.
[AGENT][NEGATIVE] Right, and how are you? I don't even understand how there's patient responsibility if it was not billed and then it was adjusted.
[AGENT][NEUTRAL] But
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Well, her name is [PII], and I think she just wants to hear it from another person, and she knew I wasn't in claims too, so she felt like I didn't know what I was saying.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII], is that her callback number, the [PII] showing, or what's your call back?
[AGENT][NEUTRAL] Mhm. [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII] and everything's been verified for the patient, right, [PII]?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, you can send her on through.
[AGENT][POSITIVE] Alright, hold on one second. Thank you, [PII]. Thanks for explaining that to me because I was doubting myself.
[CUSTOMER][POSITIVE] Sure. You're welcome.
[CUSTOMER][POSITIVE] Yeah, you're welcome.
[AGENT][NEUTRAL] All right, hold on.
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] I could see why.
[AGENT][NEUTRAL] Alright, hold on one second.
[AGENT][NEUTRAL] Hello, [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] Thank you so much for holding. I have [PII] on the line and she'll be assisting you further, OK?
[CUSTOMER][POSITIVE] Oh OK. Thank you, [PII].
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Hi [PII]