AccountId: 011433970860
ContactId: b9b8999c-9d23-4b7d-9bb4-53fe6212bef1
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 724679 ms
Total Talk Time (AGENT): 369344 ms
Total Talk Time (CUSTOMER): 207387 ms
Interruptions: 3
Overall Sentiment: AGENT=1.1, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/29/b9b8999c-9d23-4b7d-9bb4-53fe6212bef1_20250529T18:01_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII]. I have a claim that is out currently in process since, uh, some point last week. Uh, I wanted to check on the status on that to see if you guys need anything else.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Sure, I can check on that claim for you. Uh, [PII], can I get a good call back number from you first in case we're disconnected?
[CUSTOMER][NEUTRAL] Sure, [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. And is this for your policy, [PII], or are you with a provider's office?
[CUSTOMER][NEUTRAL] It's mine.
[AGENT][NEUTRAL] OK, do you have your policy number?
[CUSTOMER][NEUTRAL] 2556537
[AGENT][NEUTRAL] OK and uh what was your last name please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Alright, thank you and I'm just gonna verify some information really quick. Uh, can I get your date of birth please?
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you and can I get your mailing address?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Perfect. The last thing I need is the email address we've got on file for you. uh, looks like it is a [PII] account.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Awesome thank you for verifying all of that. OK, so looks like that most recent claim just completed processing. Give me just a moment let me take a look at that.
[CUSTOMER][NEUTRAL] Alright
[AGENT][NEUTRAL] OK, so we did pay a total benefit of $200 for this claim. It looks like for a specific procedure, um, we are missing the primary EOB. Uh, we didn't get any information showing what your primary medical, um, contributed to this procedure.
[AGENT][POSITIVE] So once we have that we'll be able to continue getting this processed.
[CUSTOMER][NEUTRAL] Oh wait, what? I'm sorry.
[AGENT][NEUTRAL] That's OK.
[CUSTOMER][NEUTRAL] I'm sorry, hold on.
[AGENT][NEUTRAL] No, no, no, you're fine.
[CUSTOMER][NEUTRAL] I, I attached the EOB on there.
[CUSTOMER][NEUTRAL] Directly from United Healthcare.
[AGENT][NEUTRAL] Oh yeah, there's just
[AGENT][NEUTRAL] Sure, uh, there's one specific procedure that is stating that, um, let me see what that one is 70547.
[AGENT][NEUTRAL] Excuse me, I'm so sorry, um, that was for a charged amount of $2000 we were able to pay the other two procedure codes that's the only other one that we were unable to.
[CUSTOMER][NEUTRAL] Which one, the neck?
[AGENT][NEUTRAL] Let me see, I'm not seeing exactly what it is. I apologize. I see the amount and the procedure code let's see.
[CUSTOMER][NEUTRAL] Cause yeah, there were 3 images that I did that day.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, this one is the charge that was $2000. Let me see if I can find something else on that.
[CUSTOMER][NEUTRAL] Yeah, they're all 3 are 2000 a piece.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, uh, [PII], if you don't mind, uh, give me just a moment I'm gonna put you on a brief hold and reach out to our claim specialist, uh, so they can take a look and review that information that was submitted to us.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, thanks one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Ferring
[CUSTOMER][POSITIVE] Thanks for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hey [PII], this is [PII] over on the care team. How are you?
[CUSTOMER][NEUTRAL] Fine, how are you?
[AGENT][NEUTRAL] Doing good thank you. I've got a member on the line uh calling regarding a midlink claim that she made. Um, let me know when you're ready I can give you that info. She wants to review what was submitted to us.
[CUSTOMER][NEUTRAL] What's the policy number?
[AGENT][NEUTRAL] That is 2556537.
[CUSTOMER][NEUTRAL] On a gasoline solar.
[AGENT][NEUTRAL] Yes, uh, and she's calling regarding just the most recent claim looks like it just finished today.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] You didn't give any benefit amounts, did you?
[AGENT][NEUTRAL] What do you mean?
[CUSTOMER][NEUTRAL] Did you give the amount of the check?
[AGENT][NEUTRAL] No, so, well she did want to just like an update, um, so I don't know if is it still processing.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It's in final processing, so, um, since, uh, yeah, the check won't print until tonight, but in case if there's any changes for some reason by the examiner, we don't wanna give an amount. I would just let them know that it's in final processing.
[AGENT][NEUTRAL] So it's not then?
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Not for the amount exactly, but the, yeah, so the procedure code the 70547 um stating that it doesn't have the primary EOB um or that we need the primary EOB for it um and she was under the impression that it had all of that information on what she submitted so she wanted to just review what was submitted.
[CUSTOMER][NEUTRAL] What was the question?
[CUSTOMER][NEUTRAL] OK, let me pull it up here, let me take a look.
[CUSTOMER][NEUTRAL] OK, so based off the EOB for that particular charge.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Nothing was applied towards their deductible co-pay co-insurance, so nothing is payable.
[AGENT][NEUTRAL] For that specific procedure that's interesting, OK.
[CUSTOMER][NEGATIVE] And nothing was paid by their primary.
[AGENT][POSITIVE] OK, OK, I'll explain that to her. I appreciate you looking. Thank you.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] You're welcome.
[AGENT][POSITIVE] Alright thanks bye bye.
[CUSTOMER][NEUTRAL] Bye.
[AGENT][POSITIVE] All right, [PII], I'm so sorry about that wait. Are you still with me?
[CUSTOMER][NEUTRAL] Yeah, I'm here.
[AGENT][NEUTRAL] OK, thanks for your patience. Uh, so we did review um what was submitted to us that primary EOB and for this specific procedure it looks like your primary didn't contribute anything to it, so nothing from our contributed to co-pay, deductible or co-insurance, so that's why we were unable to pay a benefit.
[CUSTOMER][NEGATIVE] I'm confused.
[CUSTOMER][NEUTRAL] The, the, the pri what do you mean the primary?
[AGENT][NEUTRAL] Yes, so whoever, uh, you said it was United Healthcare, that's what I mean, you're, um, major medical.
[CUSTOMER][NEUTRAL] United Healthcare is the is the medical.
[AGENT][NEUTRAL] Yes, yes, so the way that this policy works as it's a secondary medical, it is designed to help with co-pay deductible and co-insurance after your major medical pays, um, so if there's a specific procedure like this one for instance where from what we received they did not contribute anything towards this procedure, so we were unable to pay that benefit.
[CUSTOMER][NEUTRAL] Oh well, that's obvious. What, so what are you guys giving back, the 23948 that I that I paid?
[AGENT][POSITIVE] Could you repeat that? I'm so sorry.
[CUSTOMER][NEUTRAL] I'm sorry, so, uh, but I, I, that's totally understandable. Are you, are you guys paying the 23948?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So I'm not 100% exactly.
[CUSTOMER][NEUTRAL] Like, is that what I'm getting back?
[AGENT][NEUTRAL] Most likely I'm not as this is in the final stages like it looks like they're just finishing it up right now um so I won't have accurate information until either later today or tomorrow um I do see that we're paying a benefit not exactly how much though I simply see that one, procedure code that denied and I just wanted to make sure that that information was accurate.
[CUSTOMER][NEUTRAL] That's that was not generated by me so.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Um, that's, that wasn't generated by me, so I'm assuming it is. I don't know.
[CUSTOMER][NEUTRAL] That's what United Healthcare gave me, that's their explanation of benefits.
[AGENT][NEUTRAL] Yeah, no, no, that's perfectly fine, um, and again I just wanted to make sure that was accurate uh because again we're unable to pay anything unless they do for each and every procedure, um, so if for some reason they didn't pay this one or contribute anything towards this one, then we were unable to assist with that.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Let me ask you, what is the what is the maximum um annual that I'm able to get?
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] For yeah, for outpatient benefits.
[CUSTOMER][NEUTRAL] For like reimbursements for this, for co-payments. Yeah, for outpatients like uh um any other type of imaging and so forth.
[AGENT][NEUTRAL] Sure, OK, so the way that your policy works is you, you have inpatient benefits and outpatient benefits in two separate like buckets kind of thing.
[AGENT][NEUTRAL] So inpatient benefits um that's of course if you were hospitalized for longer than a day uh that pays on a per calendar year basis um your outpatient benefit pays on a per calendar day basis. So for your outpatient benefits, that's going to be anything, you know, that would take less than a day. That's the best way to think about that. So there's no yearly maximum, there's simply a daily maximum.
[AGENT][NEUTRAL] And it looks like for this policy that daily maximum is $200 per calendar day.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] So if I'm spending more than 200, then the cap is 200 per day.
[AGENT][NEUTRAL] Per calendar day, correct.
[CUSTOMER][NEUTRAL] Oh, OK, well then.
[AGENT][NEGATIVE] It is a bit confusing.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Well, it's not confusing. It's just the benefit doesn't like if I have several imaging schedules for one day, I would need to scatter that then to get the benefit.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] To get the full benefit amount, yes.
[CUSTOMER][POSITIVE] Wow.
[CUSTOMER][NEUTRAL] my own
[CUSTOMER][NEUTRAL] That's true.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right, thank you for explaining that. Do you know when um when, when it will be completed, do you know?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Oh yeah, again either later today or tomorrow at the latest I would say tomorrow morning if you wanted to um give it if you use the online portal you can look there uh or you can just give us a call if you'd like.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So you think maybe another 24 hours check-in?
[AGENT][NEUTRAL] At the most, at the most, yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Alrighty.
[AGENT][NEUTRAL] Alright, well I know that was quite a bit of information. Did you have any other questions for me?
[CUSTOMER][NEUTRAL] I'll wait. I'll maybe do it like around this time tomorrow.
[CUSTOMER][POSITIVE] No, not for the time being, thank you so much. I, oh wait, oh, I, I have the, I have, I have my account set up on there, right? So it would be directly deposited and not through mail.
[AGENT][POSITIVE] Alright, well thanks for giving us a call, of course, yeah.
[AGENT][NEUTRAL] Uh, let me verify that you have direct deposit set up. Let's see.
[AGENT][NEUTRAL] Yes, you do have direct deposit set up so I would say within um once it's completed processing um depending on your bank, of course, no longer than about 3 business days, um, some banks you know you get it really quick, but you know you could always keep an eye on those, um, you know, pending transactions and stuff as well.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Got you.
[CUSTOMER][POSITIVE] Right. OK. Well, thank you so much. I appreciate your time and your patience.
[AGENT][NEUTRAL] Of course.
[AGENT][POSITIVE] Absolutely, um, I hope you have a great rest of your day, [PII].
[CUSTOMER][POSITIVE] Thank you you too.
[AGENT][POSITIVE] Thank you. Bye-bye.
[CUSTOMER][NEUTRAL] Bye-bye.