AccountId: 011433970860
ContactId: b213eba4-8043-4bfe-8d6e-4e2abf891a5e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 814950 ms
Total Talk Time (AGENT): 383480 ms
Total Talk Time (CUSTOMER): 261487 ms
Interruptions: 1
Overall Sentiment: AGENT=0.3, CUSTOMER=1.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/01/b213eba4-8043-4bfe-8d6e-4e2abf891a5e_20250401T15:59_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How can I help you?
[CUSTOMER][NEUTRAL] Hey [PII], this is [PII] on the care team. How are you?
[AGENT][POSITIVE] Doing well [PII] thank you how are you?
[CUSTOMER][NEUTRAL] I'm doing good. Um, I have a provider on the other line. We were going through claim status and we have a remittance on file, but the denial codes asking for an EOB and she's like, well, everything's on there that's on the EOB so she's trying to talk to somebody to get more information on why this can't be used and the patient responsibilities on there.
[AGENT][NEUTRAL] Alright, let me take a look at what's the policy.
[CUSTOMER][NEUTRAL] OK, um, it's 1611562.
[AGENT][NEUTRAL] And who's the uh provider? What's her name?
[CUSTOMER][NEUTRAL] Um, her name is [PII].
[AGENT][NEUTRAL] And for
[AGENT][NEUTRAL] Which member? The insured?
[CUSTOMER][NEUTRAL] Uh, so it's part 4.
[AGENT][NEUTRAL] Part 4, OK, for [PII] it looks like.
[CUSTOMER][NEUTRAL] Oh, she was trying to, I didn't even look at it like that. She was trying to say it and I was like, I don't know. I just let her say it. She's like, I'm gonna butcher this. OK, yeah, you did it cause I was I put that together.
[CUSTOMER][NEUTRAL] Sorry.
[AGENT][NEUTRAL] That's OK. That's OK.
[CUSTOMER][NEUTRAL] She was trying.
[AGENT][NEUTRAL] Yeah, got you, OK.
[CUSTOMER][NEUTRAL] OK. So, yes, and it's um which claim number? Hold on one second.
[AGENT][NEUTRAL] And which claim number?
[CUSTOMER][NEUTRAL] Let me get on base.
[CUSTOMER][NEUTRAL] It is hold on I'm on, I was looking in on base.
[AGENT][NEUTRAL] Is it probably the 261 9?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Hold on, let me go back to M track. It's that last one there is data service [PII].
[AGENT][NEUTRAL] Maybe.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Um, we received it twice. One was a dupe, but
[CUSTOMER][NEUTRAL] Hold on, let me get out of these notes. Oh my gosh, I was trying to uh.
[CUSTOMER][NEUTRAL] Have the notes while I was on the call, but let me get back. Hold on one second.
[AGENT][NEUTRAL] OK, I think I see it here because it looks like we were 32619. OK, that's what I thought alright, I'm just gonna pull that claim up.
[CUSTOMER][POSITIVE] You got it.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Let me put that in my note.
[AGENT][NEUTRAL] 353-261-9 it looks like.
[CUSTOMER][NEUTRAL] Mhm. And then the 0018 is the dupe.
[AGENT][NEUTRAL] Yep, OK.
[AGENT][NEUTRAL] Alrighty, um, and.
[AGENT][NEUTRAL] It's gonna take a look at the EOB because what it's saying actually is.
[AGENT][NEUTRAL] Uh, OK.
[AGENT][NEUTRAL] Do you um have a call back for her?
[AGENT][NEUTRAL] Is that the number listed?
[CUSTOMER][NEUTRAL] Uh-huh, so it is.
[CUSTOMER][NEUTRAL] [PII]. I'm sorry, [PII].
[AGENT][NEUTRAL] OK, and um the patient was verified, right?
[CUSTOMER][NEUTRAL] Yes, well, this is the provider, but yes, she's verified.
[AGENT][NEUTRAL] Yeah, yeah, OK, patient information. OK, alright, if you wanna go ahead and pass her through, um, [PII], I'll try to take it from here. I'm gonna pull up the mail and just see exactly what I'm looking at, OK?
[CUSTOMER][POSITIVE] All right. Thank you.
[CUSTOMER][POSITIVE] I'm ready.
[CUSTOMER][NEUTRAL] Alrighty hold on one moment.
[CUSTOMER][NEUTRAL] Hello, [PII].
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] Thanks so much for holding. I have [PII] on the line and she'll be assisting you further, OK?
[CUSTOMER][POSITIVE] Thank you so much, [PII]. You're welcome. Thanks for calling APL. Bye-bye.
[CUSTOMER][POSITIVE] Thanks.
[AGENT][NEUTRAL] Hello [PII].
[AGENT][NEUTRAL] My name is [PII]. I'm in the claim. I'm on the claim support team and I'm taking a look at uh exactly what was submitted because it looks like we were asking for some additional information and I'm determining exactly.
[CUSTOMER][NEUTRAL] Hi [PII].
[AGENT][NEUTRAL] What that entailed.
[AGENT][NEUTRAL] So
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And this is I'm just gonna verify that I have the correct information. Data service is [PII] and the patient is uh [PII], right? [PII].
[CUSTOMER][NEUTRAL] [PII], yeah.
[AGENT][NEUTRAL] OK, alright.
[AGENT][NEUTRAL] So it looks like we were looking for that reimbursement of 2440.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] The adjuster wasn't able to determine and what happened is um it looks like we were looking for, we see the patient responsibility of 24/40 however um that it looks like the.
[AGENT][NEUTRAL] Uh, the patient remarked 242, she was questioning that, so we were asking for more, more detail of the claim, uh, showing the patient responsibility. Is this the only EOB you have?
[AGENT][NEUTRAL] Is the remark codes on a different page perhaps?
[CUSTOMER][NEUTRAL] Um, let me see.
[AGENT][NEUTRAL] Because it looks like that's what.
[CUSTOMER][NEUTRAL] So this is coming from United.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] This is coming to us from United Healthcare.
[CUSTOMER][NEUTRAL] Let's see.
[AGENT][NEUTRAL] Usually though when they have the patient remarks um they have an explanation for the patient remark code and so she's asking for uh uh the detail um of that patient remark code and the reason why is that this policy um is very specific. It will cover co-insurance and or deductible amounts for services, um, that left behind from the major medical it works at kind of hand in hand to cover those coinsurance expenses.
[AGENT][NEUTRAL] But like I said, she was questioning the um remark code. We don't have an explanation for that so do you have an additional page that you can send to us regarding the PR 3 242 remark code?
[CUSTOMER][NEUTRAL] The only thing we receive for our records is the electronic remittance report from UnitedHealthcare. I do have a code here, PR 242, uh, services not provided by network primary care providers. No this code replaces deactivated code 38.
[CUSTOMER][NEUTRAL] Um, the 2440, I know is listed under patient responsibility, but it's also listed under the XO, which if the patient has a secondary or supplemental insurance, that X over applies to that.
[CUSTOMER][NEUTRAL] The crossover.
[AGENT][NEUTRAL] OK, can you send that?
[CUSTOMER][NEUTRAL] So that crossover, if the patient didn't have a set.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Yeah, go ahead.
[CUSTOMER][NEUTRAL] If the patient doesn't have a secondary, then yes, that would be the patient responsibility. But since the patient has a secondary or supplementary policy, this would be uh applied to that.
[CUSTOMER][NEUTRAL] No. So, uh, you need a copy of the remittance report that I have, I can do that. Um, where should I send it?
[AGENT][NEUTRAL] Um, you can fax it to us. I can give you our fax number if you have, uh, the capability to fax, and then I would just reference the claim number for the original claim because when I pull up, let me just take a real quick look at this real quick, um, that was [PII], so our fax number, Clarissa is 877.
[CUSTOMER][NEUTRAL] I do.
[AGENT][NEUTRAL] 365.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 94
[AGENT][NEUTRAL] 23
[AGENT][NEUTRAL] And uh basically.
[CUSTOMER][NEUTRAL] And which is the claim number I should use as the reference?
[AGENT][NEUTRAL] Yeah, so that claim number is gonna be 353.
[AGENT][NEUTRAL] 26
[AGENT][NEUTRAL] 19.
[AGENT][NEUTRAL] And I'm looking at it looks like we received the claim a second time. Just let me take a real quick, uh, look at this. So in what the remark code reads on this original denial is that benefits are only payable if the major medical pays and uh it like I said, it's very specific to um.
[AGENT][NEUTRAL] It's saying that if the claim is later paid by your major medical send the explanation of benefits so I'm not really understanding what that uh why that remark code was used but like I said, basically what we're looking for is that patient responsibility and that code that verifies that it was the patient responsibility so it sounds like that's what you might have there um on that other page so I would um go ahead and fax that information.
[AGENT][NEUTRAL] Um, in reference that first claim of 353-261-9.
[AGENT][NEUTRAL] And ask for the claim to be reviewed.
[CUSTOMER][NEUTRAL] Ask for the claim to be reviewed.
[CUSTOMER][NEUTRAL] With the with the attached documentation OK.
[AGENT][NEUTRAL] Did you have any other questions I can answer for at this time?
[CUSTOMER][NEUTRAL] Not at this time. I will get this documentation over and about how long will it take for me before I need to uh call back and uh check in?
[AGENT][NEUTRAL] Well, the claim turnaround right now is like a 3 to 5 day, um, so I would give it, you know, maybe wait the 5 days and give us a call back if you don't, um.
[AGENT][NEUTRAL] Do you have access to our online portal at all? Do you know about that?
[CUSTOMER][NEUTRAL] Mm, no, our provider is, uh, technically out of state, out of network. Um, we just, we bill it because this is an emergency service.
[AGENT][NEUTRAL] Uh, OK.
[AGENT][NEUTRAL] Well, you can
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um, well, you could sign up under as a provider you would just need the patient, uh, you would need your tax ID number that was on the claim and also the patient account number. So I mean it's, it's an online portal where you can look up your claims, but you can just give us a call back like I said I would give it at least 5 days and then give us a call back and, and, uh, there should be a determination out there.
[CUSTOMER][NEUTRAL] OK. Um, so if I go to the website and I put in the tax ID and the numbers, um,
[CUSTOMER][NEUTRAL] Member's ID number, I should be able to view the claim determination.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Well, actually it should be the patient account number.
[AGENT][NEUTRAL] Um, that's on the claim with the tax ID you would just sign up you're saying that you're a medical or dental provider and then you put the required identified information and and again that it that would be um the tax identification number and then the patient account number um that's not listed on the claim number or on the CMS claim form.
[AGENT][NEUTRAL] The patient account number that's listed, it looks like on here it's DMDFR and then there's a series of numbers I believe you can use that along with the tax ID um and that should give you that claim status.
[AGENT][NEUTRAL] But again you would um
[CUSTOMER][NEUTRAL] Let me confirm that I have the correct account number.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] You can also use the.
[CUSTOMER][NEUTRAL] The one that's coming up.
[AGENT][NEUTRAL] The claim number that the APL claim number I think you can use that as well if you have that information, which that is one of the numbers I just provided.
[CUSTOMER][NEUTRAL] The 353-2619.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, um, the account number I have for the patient is uh [PII]. Is that it?
[AGENT][NEUTRAL] That's the one that I see on the claim form, yes.
[CUSTOMER][POSITIVE] Great. All right. I will use that to check the claim in 5 days.
[AGENT][NEUTRAL] OK, and like I said, if you need to just give us a call back as well, [PII].
[CUSTOMER][POSITIVE] All right. Thank you so much for your help. I really appreciate it.
[AGENT][POSITIVE] You're welcome and thank you so much for calling APL and thank you for your patience. I hope you have a great rest of your day.
[CUSTOMER][POSITIVE] Thanks, you too.
[AGENT][POSITIVE] Thank you bye bye.
[CUSTOMER][NEUTRAL] Mm bye.