AccountId: 011433970860
ContactId: ca00d5d8-e354-4be5-aec3-b50784e079b5
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 548659 ms
Total Talk Time (AGENT): 177377 ms
Total Talk Time (CUSTOMER): 210465 ms
Interruptions: 3
Overall Sentiment: AGENT=0.3, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/07/ca00d5d8-e354-4be5-aec3-b50784e079b5_20250207T20:27_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Oh hi [PII]. This is [PII] calling from provider's office to check members claims on a recorded line.
[AGENT][NEUTRAL] OK, I can check on a claim for you. Uh, [PII], can I get a good call back number from you first in case we're disconnecting?
[CUSTOMER][NEUTRAL] Or maybe
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Sure, it's [PII].
[AGENT][NEUTRAL] I'm sorry, that was [PII].
[CUSTOMER][NEUTRAL] Yeah, [PII]
[AGENT][NEUTRAL] OK, thank you and then do you have the policy number?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, I do. The policy number I have is 02365891.
[AGENT][NEUTRAL] OK, thank you. And what was the name and date of birth for the insured?
[CUSTOMER][NEUTRAL] Sure, short name I have is [PII].
[CUSTOMER][NEUTRAL] [PII], [PII].
[AGENT][NEUTRAL] Alright, thank you for verifying that [PII]. uh, what was the date of service for this client, please?
[CUSTOMER][NEUTRAL] Sure, data service I have.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, and then, uh, do you have the bill amount?
[CUSTOMER][NEUTRAL] Yeah, I do. The uh total bill amount for the claim, let me just provide you with that one.
[CUSTOMER][NEUTRAL] 992.
[AGENT][NEUTRAL] 99
[CUSTOMER][NEUTRAL] Uh, yes, even, and can I just have a specific question regarding the claim?
[AGENT][NEUTRAL] OK, one moment, let me locate that first.
[CUSTOMER][NEUTRAL] OK, sure.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] It's 179.
[AGENT][NEUTRAL] OK, I do believe I've found it, [PII]. um, what question did you have for me?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Perfect. Uh, actually, we received a uh payment regarding this, uh, claim for [PII], uh, the $301.60. But, uh, as far we checked here, uh, the claim was processed, uh, as
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] The number has been processed as in-network, right, or out of network.
[AGENT][NEUTRAL] Yes, yes.
[CUSTOMER][NEUTRAL] I just want to confirm, uh, was it processed in network or out of network?
[AGENT][NEUTRAL] Of course, yes, um, so this plan actually does not have a set network bundle it just pays a percentage based off of UCR.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Well I.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] You share fish, OK, need to will take the network status the claim has been produced as a network.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] You like, uh, UCR means, uh, as out of network, right? That means like
[AGENT][NEUTRAL] Could you repeat that? I'm sorry.
[CUSTOMER][NEUTRAL] Uh, UR means, uh, is out of network.
[AGENT][NEGATIVE] And no this plan doesn't participate in any network.
[AGENT][NEUTRAL] So it just goes off of uh UCR fee schedule.
[CUSTOMER][NEUTRAL] OK, so you mean to say the claim got processed correctly and paid correctly because uh we are estimating less than uh as per our schedule like uh the the claim got overpaid. Like it should be paid less than which we expected, but it's paid more.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] That you believe that this uh you received more for this claim than you should have? OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Uh yes. Uh yes, that's the thing here, so.
[AGENT][NEUTRAL] I see. OK, give me just a moment.
[AGENT][NEUTRAL] And I can verify, so we weren't able to pay on two of the procedure codes as they were not covered under this policy, and then I do see for the 4341 there were two, and one was for the upper right and the other was for the lower right.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Is that correct? And those are the two that we did pay on.
[CUSTOMER][NEUTRAL] Uh yes.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] That the.
[CUSTOMER][NEUTRAL] So I just want to confirm from your side, it is like possible like uh we will keep like this or we need to, you know, refund that money because as per our notes here like we got overpaid.
[AGENT][NEUTRAL] OK, we can definitely check um if you don't mind [PII], I'm gonna put you on a brief hold and reach out to our claims specialist, uh, to see what they think. I'll get right back with you, OK?
[CUSTOMER][NEUTRAL] Mhm. Sure.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Sure, OK.
[AGENT][NEUTRAL] OK thank you one moment.
[CUSTOMER][POSITIVE] Thank you
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][NEUTRAL] Thank you for calling American Public Life. This is [PII]. How may I assist you?
[AGENT][NEUTRAL] Hi [PII], this is [PII] over on the care team. How are you today?
[CUSTOMER][POSITIVE] I'm doing good. How about you?
[AGENT][NEUTRAL] Doing well thank you I have a provider on the line uh calling regarding a dental claim um he believes that we overpaid and he just wanted to confirm that.
[CUSTOMER][NEUTRAL] And uh I don't process the dental claims.
[AGENT][NEUTRAL] OK, I'm not quite sure. I mean, every, it looks accurate to me, um, but I'm not quite sure.
[CUSTOMER][NEUTRAL] May I have the policy number?
[AGENT][NEUTRAL] Sure, it's 02365891.
[CUSTOMER][NEUTRAL] And which claim number is it?
[AGENT][NEUTRAL] It is 354-819-3.
[CUSTOMER][NEUTRAL] OK, so the person that processed it is [PII].
[CUSTOMER][NEUTRAL] So she may know the information. I can only do benefits. I've never processed dental.
[AGENT][NEUTRAL] OK, OK.
[AGENT][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Who did you say it was? I'm sorry, [PII]?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, I'll see if she's available, yeah.
[CUSTOMER][NEUTRAL] Let me see if she's available yeah she's available.
[AGENT][POSITIVE] OK awesome alright I appreciate your help, [PII] thank you.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Bye bye.
[CUSTOMER][NEUTRAL] Bye.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEGATIVE] The person you are trying to reach is currently unavailable.
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][NEUTRAL] This is [PII]. May I help you?
[AGENT][NEUTRAL] Hey [PII], this is [PII] over on the care team. How are you?
[CUSTOMER][NEUTRAL] I'm fine. How are you?
[AGENT][NEUTRAL] Doing all right thank you. I have a provider on the line calling regarding a claim um and he said that he believes that we overpaid on it and wanted to take a look at that. I believe it was processed by um [PII], but I did try to call her. I don't think she's available um is that something you could look at or should I just try reaching out to her?
[CUSTOMER][POSITIVE] I can help him with it and pass it on, yeah.
[AGENT][POSITIVE] OK, sure, I appreciate it. Um, the policy number is 02365891.
[CUSTOMER][NEUTRAL] And what's his name?
[AGENT][NEUTRAL] Oh, his name is [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] And uh does he have a callback number?
[AGENT][NEUTRAL] Yes, it is [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And I've got that claim number too.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It is 354-819-3.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Are you ready to speak with him?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] All right, I appreciate your help, [PII]. Thank you, bye bye.
[CUSTOMER][POSITIVE] You're welcome.