AccountId: 011433970860
ContactId: c93c6c11-dc0a-4188-bb62-19772b3b0501
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1077199 ms
Total Talk Time (AGENT): 255621 ms
Total Talk Time (CUSTOMER): 210671 ms
Interruptions: 1
Overall Sentiment: AGENT=1, CUSTOMER=-1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/24/c93c6c11-dc0a-4188-bb62-19772b3b0501_20250224T14:54_UTC.wav
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[AGENT][NEUTRAL] Good morning. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, I'm [PII] calling for Augusto Health to check on a claim payment status. Please be informed that this call is being recorded and monitored for quality and training purposes.
[AGENT][NEUTRAL] OK, thank you. And I'm sorry, can you repeat your name?
[CUSTOMER][NEUTRAL] Sure, my name is [PII].
[AGENT][NEUTRAL] How do you spell that?
[CUSTOMER][NEUTRAL] Last name is [PII].
[CUSTOMER][NEUTRAL] It's [PII]. And my last name is [PII], it's [PII]
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Could you please spell your name for me?
[AGENT][POSITIVE] OK thank you.
[AGENT][NEUTRAL] That's [PII].
[CUSTOMER][NEUTRAL] One
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Last initial [PII]. You're welcome, Miss [PII]. And may I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] Sure. It's [PII]. It's a direct line.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And may I have uh the patient's policy number?
[CUSTOMER][NEUTRAL] Sure. It's 02300416.
[AGENT][NEUTRAL] May I have the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Sure. And the patient's name is [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] OK. And this is for um medical claim status?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, um, may I have the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] All right. And how much is the total charge?
[CUSTOMER][NEGATIVE] And total charge is $138 even.
[AGENT][NEUTRAL] Thank you. OK, let me see if I can find this claim for you, and for future you can check claim status online through our website at [PII], and that's just optional.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let me
[AGENT][NEUTRAL] OK, let me pull the EOB. OK, one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] I'm still waiting on the system.
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] OK, it looks like we processed the claim [PII] and we send a benefit amount of $75 which with the check, the maximum payable for the date of service has been met.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] May I know the claim processing type? Is it primary or secondary?
[AGENT][NEUTRAL] This one is not a primary or secondary. This is a limited policy.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. So, may I know the claim number?
[AGENT][NEUTRAL] Sure, the claim number for this one is 352-625-8.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] OK. And the paid amount is $75 even, right?
[AGENT][POSITIVE] Mhm. Correct, yes.
[CUSTOMER][NEUTRAL] Under the CPT code of 99213, is it?
[AGENT][NEUTRAL] 99213. Yes, that is correct.
[CUSTOMER][NEUTRAL] OK, and do you see any other claim for this member?
[CUSTOMER][NEUTRAL] Same date of service.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] For what amount?
[CUSTOMER][NEUTRAL] And I, I can see the one moment.
[CUSTOMER][NEUTRAL] I can see the uh claim number is 3525509. This is next claim number which was paid on [PII] and the total paid amount is $138 even.
[CUSTOMER][NEUTRAL] So do you see that claim? OK.
[AGENT][NEUTRAL] Give me just a second.
[AGENT][NEUTRAL] Bear with me, what is the claim number?
[CUSTOMER][NEUTRAL] It's 352-550-9.
[AGENT][NEUTRAL] OK. For August still for Augusto Medical Center. What is the procedure called?
[CUSTOMER][NEUTRAL] Same 99213.
[AGENT][NEUTRAL] Right OK.
[AGENT][NEUTRAL] OK, so this was the um the office that. Yeah, this one paid $138.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So may I know why the payment is repeated twice on the same member same date of service?
[AGENT][NEUTRAL] It's different um.
[AGENT][NEUTRAL] Let me go ahead and pull this um because this was the physician's office, the other one let me see what it was.
[AGENT][NEUTRAL] And this one is a treatment.
[CUSTOMER][NEUTRAL] Mhm. Sorry, could you please repeat it for me?
[AGENT][NEUTRAL] One was specified as an office visit, the other one was specified as a treatment. So there are two different charges.
[CUSTOMER][NEUTRAL] OK. May I know which one is specific office and which one is the worst treatments?
[AGENT][NEUTRAL] OK, the first one that we discussed, the one we send the $75 was for the treatment.
[AGENT][NEUTRAL] And the most recent one was the office visit.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So you paid the payment is correct, made the payment is correct, right? OK. And one moment, please stay online.
[AGENT][POSITIVE] Correct, yes.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Thank you for patiently waiting in line. Actually, you're saying one for office, uh, one for the provider and one for the doctor, is it?
[CUSTOMER][NEUTRAL] What sorry, one for the facility and one for the provider, is it?
[AGENT][NEUTRAL] Mm, no. Based on the explanation of benefit, one is for a treatment, one is for an office visit. I can check and see, um, but, um, and see if it was provider or facility, but those are the two that I see. We will have to do a research if you would want to go into the claim and check and see more information about it.
[AGENT][NEUTRAL] Are you seeing that it's overpaid or what, what is the reason for all your questions? I need to know so I can handle this correctly.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, because we bill only once. Yeah, yes, we bill only once on, uh, [PII]. So the payment is repeated twice on uh two.
[CUSTOMER][NEUTRAL] Just made on number 4 and also number 5.
[CUSTOMER][NEUTRAL] So that's what I'm asking for a reason for the payments.
[AGENT][NEUTRAL] So it's overpaid?
[CUSTOMER][NEUTRAL] I can see the payment is repeated twice, yes.
[AGENT][NEUTRAL] OK, um, OK, so I'll have to send this over for review, OK? Do you mind holding for me?
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Uh, so, do you have any reason for the payment?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I cannot give you that information. I will have to get that through the claims department. That's a different department, and they have to do a research on that. They will have to go into the into the claim, see the reasons of the both payments. They will have to determine if it's the same payment, if it's for the same doctor, if they will have to do a whole research. It's not something that I can give you right now over the phone if you understand.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so if you don't mind holding for me, let me go ahead and send this over for research, OK? One moment.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Thank you for holding and being patient for me, Miss [PII]. Um, can, um, can I call you back at [PII] for the update?
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Oh, don't you have any uh reason for the payment?
[AGENT][NEUTRAL] Again, I will have to send it. I'm sending it to research. Research needs to do a research, so basically they have to go through everything. I cannot give you that information over the phone, Miss [PII]. They will have to call you back and give you a reason why it was paid twice, OK? So it's not something that I can give you right away.
[CUSTOMER][NEUTRAL] So you send, uh, send the claim to research, right?
[AGENT][POSITIVE] Yes, I did. Mhm, correct.
[CUSTOMER][NEUTRAL] OK. May I know the call reference number?
[AGENT][NEUTRAL] We don't have reference numbers. You can use my name and today's date if you will.
[CUSTOMER][NEUTRAL] It's SOLM and 230 02223 2025, is it right?
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] That is correct.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] You're welcome. Is there anything else I can help you with today, Miss [PII]?
[CUSTOMER][POSITIVE] No, thank you for your assistance.
[AGENT][POSITIVE] OK, you're welcome and thank you for calling APL. Have a good day.