AccountId: 011433970860
ContactId: be9a2962-dfe2-4c7d-9371-bf1a7c64987c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 581719 ms
Total Talk Time (AGENT): 178855 ms
Total Talk Time (CUSTOMER): 334411 ms
Interruptions: 3
Overall Sentiment: AGENT=1.2, CUSTOMER=-0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/17/be9a2962-dfe2-4c7d-9371-bf1a7c64987c_20250117T13:34_UTC.wav
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[AGENT][NEUTRAL] This money
[CUSTOMER][NEUTRAL] [PII], this is [PII]. How are you today?
[AGENT][POSITIVE] I'm good how are you?
[CUSTOMER][NEGATIVE] I am terrible. I have the rudest caller on my front line. I cannot pull up the information and on base whatever for whatever reason. He is extremely rude. He is with the provider's office and I am done with him talking to me like a dog without ending the call.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The policy number is 02455568.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, and the only claim number he would give me to this point because he won't.
[CUSTOMER][NEUTRAL] 354.
[CUSTOMER][NEUTRAL] 2384. I don't wanna say anything inappropriate on this recorded line.
[AGENT][NEUTRAL] And what's his name?
[CUSTOMER][NEUTRAL] His name is [PII].
[AGENT][NEUTRAL] And which part is he looking for?
[CUSTOMER][NEGATIVE] 3. He is sick of insurance companies. He, I, I told him about the appeal. He don't wanna hear none of that. I told him about um.
[CUSTOMER][NEUTRAL] The states the primary insurance company paid in full. He don't wanna hear any of that. He was just demanding.
[CUSTOMER][NEGATIVE] That you know, so anyway he wanted how to, how to send this to me to prove that they paid and we made a mistake and on and on and on. I just threw out the fax number and that's it.
[CUSTOMER][NEGATIVE] I mean, I'm, I almost hung up on him. I have almost disconnected the call because of how he's talking to me.
[AGENT][POSITIVE] OK. I do apologize for him. I'm sorry.
[CUSTOMER][NEGATIVE] I'm very, and I am sorry, [PII]. Well, I'm sorry that you're gonna have to deal with him as well, but um uh um it's, yeah, he's extremely rude.
[AGENT][NEUTRAL] OK. I got them.
[CUSTOMER][NEGATIVE] And he's gonna have to have there's more than one claim but we couldn't even get through this one.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So I'm sorry, will you please let me know how this call turns out?
[AGENT][POSITIVE] Yes, ma'am, will do.
[CUSTOMER][POSITIVE] You're the best thank you [PII].
[AGENT][POSITIVE] You're welcome. Have a great day.
[CUSTOMER][POSITIVE] And again, I hope you do too. OK. Bye-bye.
[AGENT][POSITIVE] Thank you. Bye-bye.
[AGENT][NEUTRAL] Hi, [PII], this is [PII]. How are you today?
[CUSTOMER][NEUTRAL] I would be better if I wasn't on the phone. Did she fill you in on what's going on?
[AGENT][NEUTRAL] Uh, yes, and I'll be happy to assist you with this claim status. Please be advised verification of coverage does not guarantee the payment of a claim. So I was given claim number 35.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Don't you find it sad that you, you have to make those type of, you know, kind of responses to people when they call in, basically saying, even if we give you wrong benefits, it doesn't mean anything. Doesn't that make you sad?
[AGENT][NEUTRAL] Well, we do not give wrong benefits. We're just quoting the policy.
[CUSTOMER][NEGATIVE] 00, interesting. I've been doing this for 15 years, I probably make 1000 calls a year to insurance, and I'm not even making that up. Trust me when I tell you this, that's not a true statement. So where are we with this and why did you guys deny these claims?
[AGENT][NEUTRAL] OK, so I am looking at this claim 3542384 and it looks like
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Some lines were paid, looks like the benefit, one line was paid, and the others, it looks like the primary insurance did not, no, I'm sorry, the primary insurance paid in full.
[CUSTOMER][NEUTRAL] One line was paid.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It paid 0. How is that paid in full?
[AGENT][NEUTRAL] Because it looks like they had an adjustment.
[CUSTOMER][NEGATIVE] Benefits were exhausted.
[CUSTOMER][NEGATIVE] Mm no.
[AGENT][NEUTRAL] Looks like there was an adjustment.
[CUSTOMER][POSITIVE] It was adjusted down to patient responsibility 100%.
[CUSTOMER][NEUTRAL] Right.
[AGENT][MIXED] OK, charges exceed the fee.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] From the primary, it's not applied to their co-pay, their coinsurance, or their deductibles.
[CUSTOMER][NEGATIVE] Right? Because benefits are exhausted. It paid 0.
[AGENT][NEUTRAL] Correct. So, with this plan, it will only pay if it's applied to the co-pay, the co-insurance, and our deductibles.
[CUSTOMER][NEUTRAL] OK, so if I'm hearing you correct and I'm gonna call the mother and I'm gonna have her ask you guys for a copy of her plan description, and in there it's gonna state if a claim is denied, we will not pick it up, correct? And when I mean denied as in benefits exhausted, not, not a covered benefit.
[CUSTOMER][NEUTRAL] So if they use their benefits and they're out, so I'm gonna give you an example 2 visits per year on the [PII] visit you guys will not pick up anything, correct?
[AGENT][NEGATIVE] If the primary did not pay, we will not.
[CUSTOMER][NEUTRAL] OK, again I want you to confirm with me in the example I gave you.
[CUSTOMER][NEUTRAL] If the primary insurance stated it is a covered benefit, however, the patient has exhausted their benefits, you will not pick up any cost share. Is that correct?
[AGENT][POSITIVE] That is correct. We follow primary.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Oh OK, so your benefits are exhausted along theirs.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, so I'm going to, let's do this, so I'm gonna make a note so APL will not.
[CUSTOMER][NEUTRAL] Pay for any services that are exhausted through primary and I'm gonna have the mom file a formal complaint and then ask for a copy of the plan description to make sure that this recorded call was factual. Can I get a reference number?
[AGENT][NEUTRAL] It will be my name, which is [PII] Last initial is [PII] along with today's date.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yep.
[AGENT][NEUTRAL] [PII], is there anything else I could?
[CUSTOMER][NEUTRAL] OK, so I have other claims, yeah, so I have some other ones I'm curious about. So let's look at the same patient date of service [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] One moment.
[AGENT][NEUTRAL] OK, let's see.
[CUSTOMER][NEUTRAL] Service code 92523.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] 92523 looks like it was for $200 and looks like the primary insurance paid in full. Let me pull up the claim image.
[CUSTOMER][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Pay $56 cost share $14 right? So explain this one to me.
[AGENT][NEUTRAL] Waiting on the claim to load one moment.
[AGENT][NEUTRAL] OK, so billed amount was $200 primary pay $56 with a $144 adjustment.
[AGENT][NEUTRAL] There's no co-pay, there's no co-insurance, there's no deductible.
[CUSTOMER][NEGATIVE] No, there is a $14 co-pay. I don't know how you're getting your, so this is why I don't believe you on the first one. I think you're categorically wrong. So here's what we're gonna do.
[CUSTOMER][NEUTRAL] How would you like me to send you a copy of the explanation of benefits from the primary for all of these services?
[AGENT][NEUTRAL] You can fax it over to us at [PII].
[AGENT][NEUTRAL] 365.
[AGENT][NEUTRAL] 942-3 attention claims.
[CUSTOMER][NEUTRAL] OK, so I'm gonna send these over. What is your processing time?
[AGENT][NEUTRAL] Turnaround time is anywhere from 7 to 10 business days once it's in our system.
[CUSTOMER][POSITIVE] OK, because I'm pulling up, so just for fun, I'm gonna pull up the image that was sent to you guys.
[CUSTOMER][NEUTRAL] Right now.
[CUSTOMER][NEUTRAL] I'm curious. I'm gonna request a copy of the image you received.
[CUSTOMER][NEUTRAL] Trying to figure out how what you have is different than what I have.
[AGENT][NEUTRAL] OK, this adjudication date on this claim says [PII].
[CUSTOMER][NEUTRAL] OK, yeah, no, no, I, I have the explanation of payments here because there's a bunch of them and it's all the same thing, which is a little weird. So again, I'm gonna have the mother call you guys so that she can talk and confirm, you know, what the story is, and I'm gonna let her know that she should be asking for a copy of the plan document. You guys are gonna send that to her, correct?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] And in that plan document, it's going to specifically state benefits will not be covered if the primary denies the service.
[AGENT][NEUTRAL] I'm not sure of the wording in the policy, but she does have access to her policies.
[CUSTOMER][NEUTRAL] And again
[CUSTOMER][NEUTRAL] Well, it, it has to be there.
[CUSTOMER][NEUTRAL] Right, but it has to be there, right? It has to specifically say that.
[AGENT][NEUTRAL] That this policy will pick up the copays, the co-insurance, and our deductible. Yes, it does.
[CUSTOMER][NEUTRAL] No, you didn't follow what I'm saying.
[CUSTOMER][NEUTRAL] Right? So when I spoke to [PII], just to throw it out there on [PII] on a recorded line, she gave me some very different information.
[CUSTOMER][NEUTRAL] We'll take it from there. So I'll, I'll give mom all the information what she needs to know so that she can deal with you guys. You guys are partners. I'm not your partner. So I will let her know what the story is and you guys can chat.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Very good, thank you, thank you.
[AGENT][NEUTRAL] I
[AGENT][NEUTRAL] [PII], is there anything else I can assist you with today?
[CUSTOMER][POSITIVE] That is all I needed. Thank you so much.
[AGENT][POSITIVE] Thank you, thank you for calling American.