AccountId: 011433970860
ContactId: b2007590-795e-496a-949a-e3d18d7cce76
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1075500 ms
Total Talk Time (AGENT): 518676 ms
Total Talk Time (CUSTOMER): 348255 ms
Interruptions: 9
Overall Sentiment: AGENT=0.6, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/30/b2007590-795e-496a-949a-e3d18d7cce76_20250430T12:55_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] Hi [PII], good morning. My name is [PII]. I'm calling from Lake Charles Urgent Care. I'm calling about a, I'm calling about a claim for a patient. I was speaking with someone, uh, by email at [PII].
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] I need to clarify some information because I'm unable to pull up the claim. They actually gave me the claim number, so I did quick access and I can't pull it up and then I actually did the part where it says don't have an APL claim number, did that section and I still can't pull up this claim.
[AGENT][NEUTRAL] OK, I'll be happy to help you with this, so you're just needing to get some additional information on the claim and you aren't able to access the EOB and the portal, is that correct?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] Yes, ma'am. Well, I can help you with that and I'm so sorry. Would you give me your name again? Did you say [PII]?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So, [PII]
[AGENT][POSITIVE] Honda. OK, thank you. I'm so sorry about that. OK, and Soda, what is a good callback number for you, please?
[CUSTOMER][NEUTRAL] That's OK.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, thank you. And what is the member's policy number?
[CUSTOMER][NEUTRAL] Policy number is 0174.
[CUSTOMER][NEUTRAL] 0278 Daniel Romero.
[AGENT][POSITIVE] OK, thank you. Give me a couple of moments to get that information pulled up.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK, so under any information I provide would be a verification of benefits and not a guarantee of payment. What is the date of birth for your patient?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you and you, you said that you were speaking to someone today?
[CUSTOMER][NEUTRAL] I was speaking with someone yesterday at the email [PII].
[AGENT][NEUTRAL] Oh,
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, I think.
[CUSTOMER][NEGATIVE] And she actually gave me a claim number and like I said I still can't pull it up.
[AGENT][NEUTRAL] All right, so let's.
[CUSTOMER][NEUTRAL] And I created an account just for this claim.
[AGENT][NEUTRAL] OK, all right. And what is the data service on the and total bill amount, please?
[CUSTOMER][NEUTRAL] [PII] for $219.
[AGENT][NEUTRAL] Alright, just one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] Oh, I'm so sorry about that. I have got a tickle in my throat today. My sinuses are giving me some problems today, [PII], so I apologize.
[CUSTOMER][NEUTRAL] That's OK.
[AGENT][POSITIVE] Oh my goodness, I'm so sorry.
[AGENT][NEUTRAL] Alright.
[AGENT][NEUTRAL] OK. And is the claim number you were given 3592981?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so you already have the status, you just can't access the EOB, right?
[CUSTOMER][NEUTRAL] Yeah, and I put it
[CUSTOMER][POSITIVE] Mhm, correct.
[AGENT][NEUTRAL] Well, let's see if I can access it.
[CUSTOMER][NEUTRAL] Because she told me $25 payment um it was finalized for $23 and the payment of $25 has been issued.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, so give me just a moment to see if I can.
[AGENT][NEUTRAL] But you don't know who you, OK.
[CUSTOMER][NEUTRAL] Well someone had called me back because the office notified me on yesterday someone by the name of [PII] was trying to call me. I don't know who because when I'm looking at the um.
[CUSTOMER][NEUTRAL] Because you all send emails through a secure proof point or something, so I don't see the person, whoever it is, is it they're not um, I don't see a name.
[AGENT][NEUTRAL] OK, but you had spoken or [PII] had called you?
[CUSTOMER][NEUTRAL] Unless it's [PII].
[AGENT][NEUTRAL] I'm sorry.
[CUSTOMER][NEUTRAL] [PII] had called me unless the [PII] represents them. I don't know what [PII] uh stands for at the end of um every time they respond to me I see a [PII].
[AGENT][NEUTRAL] OK, let's see.
[CUSTOMER][NEUTRAL] I don't know.
[CUSTOMER][NEUTRAL] But anyway, she told me, uh, I, I respond, she told me the information about it was finalized and the payment and then I responded back and said I can't view the information is is why I email about it and see is there a reason why the website is saying no claims found then um the person responded back and um attached a provider user guide.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm. OK, so.
[CUSTOMER][NEUTRAL] And told me that
[AGENT][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so actually, you were given some incorrect information.
[AGENT][NEUTRAL] And I'm so sorry about that, Soda. Mhm. That's why you can't access it. That's why you can't access it. So that, we actually do not show a claim on file from
[CUSTOMER][NEUTRAL] Oh [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The provider for this data service.
[CUSTOMER][POSITIVE] Oh wow because I uploaded it um I have a confirmation number. I uploaded it on 416.
[CUSTOMER][NEUTRAL] Where it says need to file a claim, I click start here and I uploaded the HIPA and the primary EOB and I have a confirmation number.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So,
[CUSTOMER][NEGATIVE] Am I unable to upload?
[AGENT][NEUTRAL] OK, well.
[AGENT][NEUTRAL] OK, so I see.
[AGENT][NEUTRAL] I see this upload.
[AGENT][NEUTRAL] By the provider.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The reason you cannot.
[AGENT][NEUTRAL] Mhm
[AGENT][NEGATIVE] The reason you cannot see this, which you've already been given the incorrect informa I mean, you've already been given some information that I'm not sure why you were given that, to be honest. I mean, that's, I'm just trying to be truthful. It looks like this benefit has been paid to the insured.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Which is why you can't see it.
[CUSTOMER][NEUTRAL] It was paid to
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, that $25 was paid to the insured?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So with the assignment.
[CUSTOMER][NEUTRAL] Wow, OK, but that is the correct claim number.
[AGENT][NEUTRAL] It is, but again, this is, I
[AGENT][NEUTRAL] OK. What I, what I'm gonna do instead of, I would normally send a ticket to have this looked into for you, but I'm gonna transfer you to claim support to see why this was processed to the patient instead of.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] To you or to the provider since you all file the claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, and I'll give them the information when I transfer you.
[AGENT][NEUTRAL] As far as to why you're calling, but that's why you cannot see the explanation of benefits on the in the portal.
[CUSTOMER][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] OK, OK, well that, that explains it.
[AGENT][POSITIVE] OK. OK. And I'm so sorry. I don't know what happened, but I'm gonna, um,
[AGENT][NEUTRAL] Like I said, since this just occurred and you've spoken with [PII] and you've also been receiving emails about it, give me just a minute to get you connected with someone, OK?
[CUSTOMER][NEUTRAL] OK, do you have a call reference number for me?
[AGENT][NEUTRAL] You, you would use as far as for our portion of the call, my name in today's date.
[CUSTOMER][POSITIVE] OK, alrighty, thank you so much for your help.
[AGENT][POSITIVE] All right then, well, yes, and you're welcome and again thank you for calling APL if that's all I can help you with. Give me just a moment, son, and I'll get you connected with someone to look at that.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Alright, yes ma'am, one moment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Transferring.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Good morning. Thanks for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hey, [PII], it's [PII]. Good morning. How are you?
[CUSTOMER][NEUTRAL] Fine, how are you?
[AGENT][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.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] 1740278.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Yes, ma'am. OK, so the claim number is 3592981.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so I have a provider on the line. Her name is [PII]
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][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.
[AGENT][NEUTRAL] And she was given the claim status, given the the paid amount.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] But the provider filed a claim in the portal and it shows a P in the portal.
[AGENT][NEUTRAL] But this indicates that we issued payment to the insured.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, let me look, let me pull it up.
[AGENT][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.
[CUSTOMER][NEUTRAL] It's not, it was submitted by the provider. I'm looking at the form because I really can't see there's an X because 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 because 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.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] CMS, it didn't pull over properly on their CMS form.
[CUSTOMER][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.
[AGENT][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.
[CUSTOMER][NEUTRAL] I don't know if the examiner reached.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] The amount paid.
[AGENT][NEUTRAL] and all of that.
[CUSTOMER][NEUTRAL] OK, let's see here.
[AGENT][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.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] I mean, I did tell her that because she already had the amount. I mean everything.
[AGENT][NEUTRAL] She was just trying to get an EOB.
[CUSTOMER][NEUTRAL] I wanna, I'm trying to see if, no.
[CUSTOMER][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.
[AGENT][NEUTRAL] Nope, there is nothing of that. Nope.
[CUSTOMER][NEUTRAL] No
[AGENT][NEUTRAL] Sure it's not.
[CUSTOMER][NEUTRAL] Yeah, that claim, yeah, it should have been issued to the provider. That ex[PII] have to reprocess the claim.
[CUSTOMER][NEUTRAL] Reprocess that claim to the provider.
[AGENT][NEUTRAL] OK. And what, request a refund from the insured?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yup.
[AGENT][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] Yeah.
[AGENT][NEUTRAL] Have been
[AGENT][NEUTRAL] I, I don't kinda know, I really don't know what to do with this one.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][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.
[AGENT][NEUTRAL] I just
[AGENT][NEUTRAL] OK. And will you do that or do I need to send a hub ticket?
[CUSTOMER][NEUTRAL] If you will send a hub ticket.
[AGENT][NEUTRAL] That's
[AGENT][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.
[CUSTOMER][POSITIVE] You, you're welcome.
[CUSTOMER][POSITIVE] OK, thanks.
[AGENT][NEUTRAL] OK, [PII], thank you. All right, bye-bye. All right, bye-bye.
[CUSTOMER][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Bye.
[AGENT][NEUTRAL] [PII], this is still [PII]. OK, so look, what I'm gonna do is I'm just going to send a request to have this claim reprocessed.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Because according to the information, I mean, I can see that the provider did file it so it's just gonna have to be reviewed and reprocessed. So once that has been done, um.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Payment should be issued to the provider once it's reprocessed.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] But they'll do a little bit of research on it.
[CUSTOMER][NEUTRAL] But uh so a check hadn't been.
[AGENT][NEUTRAL] Yeah, I think
[CUSTOMER][NEUTRAL] OK, check hadn't been cut to the patient yet, although it was finalized on [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Oh, yes, it has. So we'll have to, that'll all have to be reprocessed too as far as getting, you know, requesting a refund back from them just like we would for a provider if we paid and should not have paid the provider. So yes, so it's gonna take us a little time. I'm sorry that that happened. I'm not sure exactly why. Um.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, I'm, I'm just, I'm sorry. I, I can't answer that, but I am gonna send the request to have that reprocessed.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Researched and reprocessed.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] They searched and reprocessed.
[AGENT][NEUTRAL] Yes, ma'am. Mhm.
[CUSTOMER][NEUTRAL] So allow like how long you think?
[AGENT][POSITIVE] Um, I would definitely give it another, you know,
[AGENT][NEUTRAL] Uh, let's see, today is Wednesday. I mean, I, I think that as far as the.
[AGENT][NEUTRAL] Probably by next Wednesday, give us about 7 business days. It could be done 7 to 10 business days is standard, um.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] On this type of thing.
[AGENT][NEUTRAL] But then give it, you know, I mean, maybe give us till next Friday and hopefully, that would have been resolved.
[CUSTOMER][NEUTRAL] OK, because you are gonna have probably gonna have to contact the patient to the.
[AGENT][NEUTRAL] Mhm. Correct. Yes, ma'am. So, you know, it could take a little longer. I don't, I don't have a definitive time, so that, that I can really
[CUSTOMER][NEUTRAL] OK, alright.
[CUSTOMER][NEUTRAL] Bye.
[AGENT][NEUTRAL] Give you a, a hard line answer, but give us approximately 7 to 10 business days.
[CUSTOMER][NEUTRAL] That's, that's fine.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, alright, well I'll just check by by next Friday if not the next Friday, maybe the Monday after I'll check um back with you all to see. OK, well thank you very much for all your help.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK. And again, I am sorry about the confusion. Yes, ma'am.
[CUSTOMER][POSITIVE] That's, that's OK have a great day.
[AGENT][POSITIVE] Oh, OK. Well, it's, yeah, I hope you have a great day too, and if that is all I can help you with at the moment, thank you again for calling APL.
[CUSTOMER][POSITIVE] OK thanks bye bye bye bye.
[AGENT][NEUTRAL] All right. See you. Bye-bye.