AccountId: 011433970860
ContactId: bc1209d5-3fcc-42be-a6c4-a6f38ed021c4
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 504179 ms
Total Talk Time (AGENT): 153254 ms
Total Talk Time (CUSTOMER): 159370 ms
Interruptions: 0
Overall Sentiment: AGENT=0.6, CUSTOMER=-0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/08/bc1209d5-3fcc-42be-a6c4-a6f38ed021c4_20250108T19:05_UTC.wav
--------------------------------------------
[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], I have a claim here.
[CUSTOMER][NEUTRAL] That uh you guys are secondary payer United applied a large amount to the patient's deductible and you guys paid one line item out of the 123456.
[CUSTOMER][NEGATIVE] Line items that we build and I'm looking at your EOB and it says there's a remark #1 and remark number 2 but there's nowhere on this EOB that I see what that means. I don't know what 1 stands for or what 2 stands for.
[AGENT][NEUTRAL] OK, I can help you with the claim. And may I have your name and a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Sure. [PII] and my name is [PII].
[AGENT][NEUTRAL] OK, and [PII], may I have either the policy number or the claim number?
[CUSTOMER][POSITIVE] Sure. My computer will work with me here.
[AGENT][POSITIVE] Oh, take your time.
[CUSTOMER][NEUTRAL] It is 02489440 M for Mike L for Lima 8.
[AGENT][NEUTRAL] Thank you for that. And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] [PII], [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the date of service for the claim?
[CUSTOMER][NEUTRAL] [PII] for [PII].
[AGENT][NEUTRAL] OK, and all the information provided is a verification of benefits, not a guarantee of payment. And, do you mind if I place you on just a brief hold while I research the claim for you?
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] All right, hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Lea.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] Thank you so much for holding. I apologize for that wait. So I do see what's going on here. Um, on your explanation of benefits, do you have one page or two?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEGATIVE] I see one page with a chest and I see a 2nd page and it says remark description, but it's completely blank.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so I will fax you over another copy of the explanation of benefits, but the calendar year or calendar day max for this policy is $500. So, that's why majority of these codes were denied because once that $500 is met, we can't go over it for that day. Um, so let me go back to the claim.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So it's $500 per day.
[AGENT][POSITIVE] Yes, ma'am, for the outpatient benefits.
[CUSTOMER][NEUTRAL] So how come we only got $174 and change?
[AGENT][NEUTRAL] Hold on one moment, I'm going back to the claim now.
[AGENT][NEUTRAL] Because there were other claims that came in, there's another claim here for this data service that also received the payment, so it's not just, it's for any claim that comes in on this data service.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Was it from our facility? The other claim?
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] No, this is uh for imaging.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Alright, hold on.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] You're saying there were two claims, OK.
[AGENT][NEGATIVE] You, I can't hear you anymore. You sound really far away.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Oh hi, sorry, hold on just a sec. I'll take you.
[AGENT][NEUTRAL] It's OK. OK.
[CUSTOMER][NEUTRAL] Alright, so I see that we billed you for $248 on [PII], which we have not received payment. Let me see, hold on a second.
[CUSTOMER][NEUTRAL] Yeah, still out to United OK.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] I guess I'm a little confused. You received another claim not from our facility though. It's gotta be a different facility?
[AGENT][NEUTRAL] Right, we received two claims for this data service. The other claim came in before your claim did, so majority of the 500 was applied to that claim. The reason you received the amount you did is because that's the remainder of the 500 for [PII].
[CUSTOMER][NEUTRAL] But I'm not seeing that $500 on so let's just pretend you paid us $170 so roughly you paid over $300 on another claim is what you're saying you paid it to us?
[AGENT][NEUTRAL] No, it's a different provider.
[CUSTOMER][POSITIVE] Thank you, that's what I needed to know.
[CUSTOMER][NEGATIVE] I'm looking at my system and I'm not seeing any more money.
[AGENT][NEUTRAL] Oh, that's what I'm sorry, that's what I meant when I said it's not your claim. My apologies.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] OK, alright, great, so is there a reference number for the call?
[AGENT][NEUTRAL] Um, so there's no call reference number, but you can use my name and today's date. So that's [PII]
[AGENT][NEUTRAL] The first initial to my last name is [PII], and then today's date.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, um
[CUSTOMER][NEUTRAL] I was gonna ask you something, um, is this patient responsibility because he's met his maximum?
[AGENT][NEUTRAL] So now, we don't determine patient responsibility because we're not the major medical. So whatever the protocol is for outstanding balances, uh, it would be between primary and um you as the provider.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And did you, did you need me to fax you another copy of the explanation of benefits because that 2nd page there is what tells the remark the description of the remarks.
[CUSTOMER][NEUTRAL] Right, no, that's OK. I, I probably won't get it.
[AGENT][NEUTRAL] All right. Well, was there anything else I could assist you with today?
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Uh, you know what, let me try something. I might have you fax that. Let me think a minute here.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I have to go
[CUSTOMER][NEUTRAL] No, because I just got rid of that, never mind.
[CUSTOMER][POSITIVE] Alrighty well thank you so much I appreciate your help.
[AGENT][POSITIVE] You're very well thanks for calling APL and I hope you have a great day and happy new year.
[CUSTOMER][POSITIVE] Thank you. You too, hon. Bye bye.
[AGENT][NEUTRAL] Bye bye.