AccountId: 011433970860
ContactId: d707103e-183c-4400-ac4f-cca81c44f315
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 680099 ms
Total Talk Time (AGENT): 188950 ms
Total Talk Time (CUSTOMER): 209302 ms
Interruptions: 0
Overall Sentiment: AGENT=0.3, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/01/d707103e-183c-4400-ac4f-cca81c44f315_20250401T14:15_UTC.wav
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[AGENT][POSITIVE] Thanks for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yes, good morning, [PII]. um, I'm trying to find out there was a claim that was recently filed and it looks like it was already processed, but I wanted to get information. I was online trying to get some information regarding the claim, but it doesn't want to load. Um, can you help me find out what that was about?
[AGENT][NEUTRAL] That's
[AGENT][NEUTRAL] Sure, are you with the provider's office or is this for yourself?
[CUSTOMER][NEUTRAL] Myself.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And what was your name?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And [PII], do you have a good callback number?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And do you have your policy number handy?
[CUSTOMER][POSITIVE] Um, I could get it for you if you, yeah.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] That is um.
[CUSTOMER][NEUTRAL] Well, I have an inpatient, outpatient. Is that the same number?
[AGENT][NEUTRAL] Well, I have a new patient.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK. 024.
[CUSTOMER][NEUTRAL] 055.
[CUSTOMER][NEUTRAL] 22.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] And then MLA would be for the outpatient benefit.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And just need to verify a few pieces of information. What is your birthday?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And your address?
[CUSTOMER][NEUTRAL] Right now it's uh [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, and then what was that date of service on the claim or date of service for your ser um doctor's visit?
[CUSTOMER][NEUTRAL] 3, I think [PII]. Yeah, I think [PII].
[AGENT][NEUTRAL] OK, let's see.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] OK, what was the amount that you submitted?
[CUSTOMER][NEUTRAL] I well I don't know what they submitted so um.
[AGENT][NEUTRAL] Oh, OK. It was the provider.
[CUSTOMER][NEUTRAL] That's what I was trying to, yeah, that's what I was trying to find out the information because I made a payment they said that it was, uh, they were trying to process it while I was there, uh, under, I don't know, whatever code that they use for outpatient services, um, because it was an urgent care facility and they said they they couldn't process it so they took like a payment from me.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And they said that they were gonna try, um, but I don't know if that's what that was.
[AGENT][NEUTRAL] Let's see, so.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEGATIVE] And I just don't wanna pay for it twice.
[AGENT][POSITIVE] Yeah definitely understand.
[AGENT][NEUTRAL] Was it MD now, does that sound right?
[CUSTOMER][POSITIVE] Yes, 70 now, yes, that's correct.
[AGENT][POSITIVE] OK, perfect.
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] OK, yeah, it looks like they did for uh send the claim in, but it showed that your primary insurance paid in full.
[AGENT][NEGATIVE] So there was no benefits payable.
[CUSTOMER][NEUTRAL] Oh, so there was nothing, OK.
[AGENT][NEUTRAL] Yeah, so, so.
[CUSTOMER][NEUTRAL] So, but did they, but did they make some and did they make any kind of claim at all?
[AGENT][NEUTRAL] They did. They submitted the claim, but we denied it stating that your primary insurance paid in full, so there was no benefits payable.
[CUSTOMER][NEUTRAL] OK, and what was the claim, how much was the claim for?
[AGENT][NEUTRAL] 6:16.
[CUSTOMER][NEUTRAL] 660?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, alright, so, alright, uh, what I don't know is does that include like the it was like a copay, like 80, I think it was $89. Was that included in that? Can you tell?
[AGENT][NEUTRAL] Um, they just build, let's see, let me pull up what they.
[AGENT][NEUTRAL] Let's see uh.
[CUSTOMER][NEUTRAL] And I'm sorry to ask you these questions. It's just that I don't have access online, otherwise I would just get it.
[AGENT][POSITIVE] Oh, no, no, no worries. That's what I'm here for.
[AGENT][NEGATIVE] Uh, just give me one moment. This runs just a bit slow.
[CUSTOMER][POSITIVE] OK, thanks. I appreciate that.
[AGENT][NEUTRAL] Let's see, pull up what they were sent.
[AGENT][NEUTRAL] OK, so they submitted.
[AGENT][NEUTRAL] $616. It was just one line, so it's just one charge.
[AGENT][NEUTRAL] Looks like
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Excuse me.
[AGENT][NEUTRAL] Yeah, they just submitted 11 code with a billed amount of $616 and then they submitted your Aetna um explanation of benefits.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Did you pay $85 that day?
[CUSTOMER][NEUTRAL] Yeah, OK, 85. I didn't know if it was 85 or 89. Yes, I did.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So that was included.
[AGENT][NEUTRAL] Was this like an urgent care visit?
[CUSTOMER][NEUTRAL] Yes
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me see.
[CUSTOMER][NEUTRAL] Yeah, I think I had like symptoms of COVID, but it was already on the 10th day.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Trying to pull up. I'm pulling up your policy to make sure that I've got the right benefits what to pay for an actual urgent care.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] Give me one moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] so
[AGENT][NEUTRAL] OK, um, can I place you on a brief hold?
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][POSITIVE] Absolutely.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEGATIVE] Not understanding.
[AGENT][NEUTRAL] Oh there
[AGENT][NEUTRAL] So,
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, thank you so much for holding yeah so what happened is they submitted the explanation of benefits from Aetna and it doesn't show that you have any patient responsibility so therefore that's why this claim didn't pay um because that's what we look at is the explanation of benefits from your primary.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So yeah, so that's because that explanation of benefits does not show a patient responsibility.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Therefore we didn't pay anything on the claim because we're only gonna pay if there shows a patient responsibility.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Does that make sense?
[CUSTOMER][NEUTRAL] OK, so, yeah, no, it does definitely, so I should probably check with Aetna and see if they, uh, paid my, um, my co-pay when I went through the $85 because technically usually when I had um used APO in um [PII] now I'm in like in the [PII] area in [PII] I never had to pay anything.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] But they couldn't process that um co-pay at the time I went to the, uh, and did the visit because they said it wouldn't take in their system for some reason. I don't know what it was, so I don't know if I should be reimbursed for that $85 somehow, um, and if so, then maybe they need to do something different on their end in order for the claim to come through.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, so I would definitely reach out to Aetna and just explain to them you have the secondary insurance, you know, the explanation from Aetna doesn't show anything due, and then you can also reach out to your provider as well, um, and, and see if, you know, will they be refunding that money or how will that work?
[CUSTOMER][NEUTRAL] Uh-huh, OK.
[CUSTOMER][POSITIVE] Right, OK. All right, good, thank you. I appreciate it. um, I'll find out the information. If I need anything I'll call back.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK, well, perfect. Well, thank you for calling APL [PII]. I hope you have a great day.
[CUSTOMER][POSITIVE] Thanks. You too, [PII]. Bye-bye.
[AGENT][NEUTRAL] Bye.