AccountId: 011433970860
ContactId: d2444e13-8cb5-4588-9f89-76e7b0843a1f
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 614270 ms
Total Talk Time (AGENT): 243666 ms
Total Talk Time (CUSTOMER): 285330 ms
Interruptions: 6
Overall Sentiment: AGENT=0.4, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/12/d2444e13-8cb5-4588-9f89-76e7b0843a1f_20250512T15:00_UTC.wav
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[AGENT][NEUTRAL] Hey, thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey [PII]. Oh hey [PII], this is [PII]. How are you?
[AGENT][NEUTRAL] Fine, how are you?
[CUSTOMER][NEUTRAL] I'm doing good. I feel like after the trade and now I could put faces to the names. Um, I have an insured, well, I'm sorry, I have a provider on the other line. Um, it's policy number 239.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 9312.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The rep, the um provider's name is [PII]. So he was calling originally for part two.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Claim number 3,553,290.
[CUSTOMER][NEGATIVE] We denied it requesting an explanation of benefits.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] But then he says, so why did you pay for [PII] as primary? And I said, well, we didn't, this is a secondary policy. So the, the claim he's referencing now is 3552666.
[CUSTOMER][NEUTRAL] When I pulled up the documents and on base, there is no explanation of benefits. So maybe that's why he feels that way and we did pay out.
[AGENT][NEUTRAL] So this is for the office visit for one night?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, this, yes, this is the, the office visit for outpatient. We don't need the EOB to pay the, cause it's the indemnity.
[AGENT][NEUTRAL] It's on the rider, on the physician rider, it pays that limited benefit of $25.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] But as far as the outpatient benefits or inpatient, we have to have the EOB on those ones. But since this is just a physician, outpatient rider, we don't need the.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] You'll be.
[CUSTOMER][NEUTRAL] The explanation of benefits. OK. I'm gonna write that down. Um.
[AGENT][NEUTRAL] Mhm, yeah.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Can you talk to him? I mean, I could explain that, but he, with the rebuttals, in case he come back with something else.
[CUSTOMER][NEUTRAL] Um, and he wants to talk to somebody else.
[AGENT][NEUTRAL] Sure, I can explain that under the physician writer, um, the SY benefits are paid because it's just a writer under the plan, but the inpatient, outpatient, we will have, you'll be as required since we're secondary. I can explain it to him. You said his name is [PII]?
[CUSTOMER][NEUTRAL] And just for, mhm, and just for me, so this is for like Medli period, if it's a like a dis like a writer like that.
[AGENT][NEUTRAL] For this plan, for this coverage, for the MetLin 4, they have the outpatient physician writer. Now, however, under the other med links, um, like the newer medlings, cause this is a Metlink 4 and those was prior, we don't cause they have the, it's the physician writer. But the other ones like medling 5 and above, the, we have to have the EOP cause it's either gonna be either for um specialist visit or primary care visit. Yeah.
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Office, OK.
[AGENT][NEUTRAL] It pays differently for those benefits.
[CUSTOMER][NEUTRAL] I got it.
[CUSTOMER][NEUTRAL] OK. Well, thank you for explaining that to me. Hold on one second, OK?
[AGENT][POSITIVE] Mhm. You're welcome.
[CUSTOMER][NEUTRAL] Hello [PII].
[CUSTOMER][NEUTRAL] Yeah, I'm here.
[CUSTOMER][POSITIVE] Thank you so much for holding. I have [PII] on the line and she'll be assisting you further, OK?
[AGENT][NEUTRAL] Hello, [PII].
[CUSTOMER][NEUTRAL] Yeah, OK.
[CUSTOMER][NEUTRAL] Yeah, hi, this is [PII].
[AGENT][NEUTRAL] Hi.
[CUSTOMER][NEUTRAL] Yeah, yeah, for this one, I stated the claim was denied due to need timer youB, but upon checking our records, we received payment from previous claims for, uh, the same insurance.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] What
[AGENT][NEUTRAL] And this is in regards to the data service of [PII]?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Yes, yes, yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And this was in regards to.
[CUSTOMER][NEUTRAL] Yeah, we receive $25.
[AGENT][NEUTRAL] OK, it looks like the claim number that you were calling in regards to was for the billed amount of $323.10.
[AGENT][NEUTRAL] Is that correct?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Just a second, um, for which one? I'm calling for, um, for the amount of $174.60 but our previous paid claim was, uh, $500.20 $500,520.95.
[CUSTOMER][NEUTRAL] The plan is processed.
[AGENT][NEUTRAL] OK, so you're calling in regards to, you said the bill amount is $174.60?
[CUSTOMER][NEGATIVE] Yes, that was the claim where we obviously denied.
[CUSTOMER][NEUTRAL] Uh, due to the primary EOB, but upon checking all the costs, we receive payment for the date of service [PII] with the bill amount of $520.95.
[AGENT][NEUTRAL] OK, let me take a look.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Yeah, sure.
[CUSTOMER][NEUTRAL] Be
[CUSTOMER][NEUTRAL] And I get the claim.
[CUSTOMER][NEUTRAL] OK and is it uh.
[AGENT][NEUTRAL] OK, so the, the claim that you referenced the bill amount was for $520.95.
[CUSTOMER][NEUTRAL] The
[CUSTOMER][POSITIVE] Yes, yes, yes, that's correct.
[AGENT][NEUTRAL] [PII], OK, so on that claim, [PII], I do show we paid a benefit of $25. Under this plan, it pays a benefit of $25 for the office visit and that's the max payable for the office visit.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mhm, yes.
[AGENT][NEUTRAL] So they've met their max for that data service for that office visit. It only covers a max of $25.
[CUSTOMER][NEUTRAL] Yeah, on that claim, we said.
[CUSTOMER][NEUTRAL] You mean, um.
[CUSTOMER][NEUTRAL] Yeah, that's correct, but that claim was processed as primary, right?
[CUSTOMER][NEUTRAL] ask you right.
[CUSTOMER][NEUTRAL] That reference claim number $520.95. So that was processed as a primary and right.
[AGENT][NEUTRAL] We're secondary.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] So under this coverage, we only cover a max of $25 for the office visit. That's the max payable.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Uh sorry, I didn't understand which means.
[AGENT][NEUTRAL] We did not there, there was no EOB received on this particular claim. However, since we are secondary for this particular benefit, the physician office benefit, we only cover $25 max. That's the max payable under the coverage as secondary.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. Uh, on the claim also you have processed the secondary, right?
[AGENT][NEUTRAL] Yes, we process a secondary with this.
[CUSTOMER][NEUTRAL] On the [PII].
[AGENT][NEUTRAL] We're secondary. We're not major medical.
[CUSTOMER][NEUTRAL] Yeah, you have processed that.
[CUSTOMER][NEUTRAL] Uh, you have processed a secondary under the claim number, uh, well, just a second, the claim number 3552666, right?
[AGENT][POSITIVE] Correct, that is correct.
[CUSTOMER][NEUTRAL] Your process as secondary.
[CUSTOMER][NEUTRAL] OK. Uh, for this claim, you need a primary for the data service of [PII] the bill amount of $174.60 I'm right?
[AGENT][NEUTRAL] You said for [PII]?
[CUSTOMER][NEUTRAL] Yeah, [PII].
[AGENT][NEUTRAL] OK, let me take a look at that data service.
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] OK. We did request the primary explanation of benefits. However, we'll send a request to get this claim reprocessed. This is just a physician um rider benefits, so we can't consider benefits with without the explanation of benefits. So I'll send a request to get this benefit, this claim reprocessed.
[AGENT][NEUTRAL] Is there anything else I can assist you with today, [PII]?
[CUSTOMER][NEUTRAL] You mean the other thing?
[CUSTOMER][NEUTRAL] OK. OK. Uh, which claim, uh, uh, for the reference claim, that claim was paid as a second processed as secondary only. And so for that, for the, for this one, you need a primary UV for this claim, right? And the primary is 8 now, and the COB was lastly updated on [PII]. I'm right.
[AGENT][NEUTRAL] We have not received a primary explanation of benefits. However, since this particular claim is under the physician writer, we can't consider benefits without the explanation of benefits for this claim, which is 3,553,290. I'll submit a request to have this claim reprocessed.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, OK. Who is, OK, who is famous for this station?
[CUSTOMER][NEUTRAL] Sorry?
[AGENT][NEUTRAL] You have to contact the patient to obtain that information for who's their major medical.
[CUSTOMER][NEUTRAL] OK, that's it. I'm fine.
[CUSTOMER][NEUTRAL] OK, I'm just asking for the information. Uh, who is primary for this patient? This is A now or?
[AGENT][NEUTRAL] You have to contact the, the patient to obtain that information to see who their, their primary is for that time frame.
[CUSTOMER][NEUTRAL] And I stated it was 8 now.
[CUSTOMER][NEUTRAL] Mhm and.
[CUSTOMER][NEUTRAL] OK, for this primary for this patient, we need to contact the patient, right?
[AGENT][NEUTRAL] Yes, cause the claim information that was submitted to us, it does not provide that information to us. So you'll need to notify the patient to obtain who their major medical insurance carrier is.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] At least you can provide when.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. uh, thank you very much. Could you please provide a call reference number?
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] It'll be just my name, and that's [PII] spelled [PII] Is there anything else I can assist you with today, [PII]?
[CUSTOMER][NEUTRAL] No need, you know.
[AGENT][POSITIVE] OK, well, thanks for calling [PII]. You have a good day. Bye.