AccountId: 011433970860
ContactId: dbf052be-5f39-4dba-a670-58c20a131915
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 399540 ms
Total Talk Time (AGENT): 205855 ms
Total Talk Time (CUSTOMER): 163001 ms
Interruptions: 4
Overall Sentiment: AGENT=0.3, CUSTOMER=-0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/18/dbf052be-5f39-4dba-a670-58c20a131915_20250218T18:23_UTC.wav
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[AGENT][NEUTRAL] Contacting APL, my name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII] um I was calling to.
[CUSTOMER][NEUTRAL] was my bro my brother's name [PII] instead of [PII]. I don't know why. Maybe he's thinking about me. Um, I was calling because it says that um an EOB was needed but it was faxed with um the claim.
[AGENT][NEUTRAL] OK, we can look that up. Um, what is your policy number?
[CUSTOMER][NEUTRAL] Um, I'm actually a provider and it's 02569076.
[AGENT][NEUTRAL] OK, thank you. And I'm sorry, I didn't catch your name.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Sure
[AGENT][NEUTRAL] Great, thank you. And uh sir, what is the insured's name and date of birth, please?
[CUSTOMER][POSITIVE] Alright thank you and
[CUSTOMER][NEUTRAL] It's [PII], sorry, and her date of birth is [PII].
[AGENT][POSITIVE] I do appreciate that. If I can have a callback number uh while I'm looking this up.
[CUSTOMER][NEUTRAL] Yes ma'am, it's [PII].
[AGENT][NEUTRAL] OK, great. Um,
[AGENT][NEUTRAL] I appreciate that. I'm just looking that up. And what is the date of service? Is it, is it the [PII] that we're looking at?
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] No, it's [PII].
[AGENT][NEUTRAL] [PII]. OK.
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] It's
[CUSTOMER][NEUTRAL] I have a claim number if that would help.
[AGENT][NEUTRAL] Yes, please.
[CUSTOMER][NEUTRAL] Um, 356-046-7.
[AGENT][NEUTRAL] Ah, OK. I see.
[AGENT][POSITIVE] OK, great.
[AGENT][NEUTRAL] And what I'm doing right now is I'm just pulling up the, the documents that we, that we have and we can see what has gone on with this.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I know when I called the last time they told me that I had um an older member number but.
[CUSTOMER][NEUTRAL] Uh, sent the one I think that.
[CUSTOMER][NEUTRAL] I really don't know which one I sent. I may have updated it and sent the new one. I'm not sure.
[AGENT][NEUTRAL] OK. Um, so let me, uh, let's, uh, this is the, this is the EOB that I have for uh Great Western Healthcare Cigna.
[CUSTOMER][NEUTRAL] So let me um
[AGENT][NEUTRAL] Um, this is for Florida Eye Microsurgical Institute. So, um, what I've got is it, uh, it shows a CPT code of 92012, and on our claim form it says 92015. Now the, the, um, builded amounts are different too. One says $175 and then um it looks like on our claim it says $70. So I'm just gonna look at the, there's a second part to the COB and see if I can't.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] This is
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, so then there's another section. Yeah, there is another section that's um uh 92015, um, but what it says on that one, it says uh uh PR 96. It uh instead of a deductible co-payment or co-insurance, it says PR 96. And when we looked at that, um, it looks like that's non-covered charge, uh, with at least one remark code, uh, that must be provided. So,
[CUSTOMER][NEUTRAL] Yeah, there should have been 2.
[CUSTOMER][NEUTRAL] Yeah, but there is another
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] That
[AGENT][NEUTRAL] On that particular charge, and this is the one that's $175.
[CUSTOMER][NEUTRAL] On
[AGENT][NEGATIVE] The EOB that we received, uh, um, [PII], it shows that uh that it wasn't paid. It shows $17.20 being due, but what, what they've done is they've put that as being PR 96, which, which on the uh little glossary underneath that says that 96 means non-covered charge.
[CUSTOMER][NEUTRAL] be that we received.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And because they didn't put it towards the deductible co-payment or co-insurance, that's, that's uh what, so the EOB was sent. You, you're right, the EOB was certainly sent on that. Um, it's just that the EOB that we received, uh, showed that uh that particular charge, um.
[CUSTOMER][NEUTRAL] Because
[CUSTOMER][NEUTRAL] But
[AGENT][NEGATIVE] Wasn't covered.
[AGENT][NEUTRAL] And sometimes if you have another EOD.
[CUSTOMER][NEUTRAL] Right, so they have that because the code itself is 92015, right? That's the one you're speaking of?
[AGENT][POSITIVE] Right, that's correct. Yes.
[CUSTOMER][NEGATIVE] Right, the, the actual like, like the primary did that wrong. The charge for that is $70 not $175.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEGATIVE] And I can't get them to fix that.
[CUSTOMER][NEUTRAL] But it is a non-covered charge they typically don't cover refractions.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] And y'all don't cover office visits?
[AGENT][NEUTRAL] Right, so there's nothing about this that, yeah, so there's nothing about the claim that we would that we would cover because we wouldn't cover the office visit and since they, uh they are not covering this, um.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] They're putting it as being a non-covered charge. see that we'll only pick up the deductible co-payment or co-insurance if it is, if it is allowed by the uh uh major medical, in this case, Cigna.
[CUSTOMER][NEUTRAL] I know when we pick up.
[AGENT][NEUTRAL] So that's why this, that's why you got the EOB that you got it, it's just that there's there.
[CUSTOMER][NEUTRAL] So the, the [PII], even though the patient had a responsibility of 7287 as a co-pay because you don't cover office visits, you wouldn't do that, right?
[AGENT][POSITIVE] That's right. That's correct.
[CUSTOMER][NEUTRAL] OK and then.
[CUSTOMER][NEUTRAL] The [PII] they have the wrong amount but they put.
[CUSTOMER][NEUTRAL] And allowed amount of 17, so it's just patient responsibility, OK.
[CUSTOMER][NEUTRAL] Alright.
[AGENT][NEGATIVE] Yeah, cause it's um yeah, if they don't cover it, uh, yeah, then I'm afraid we, we, we wouldn't cover it either.
[CUSTOMER][POSITIVE] Well thank you.
[CUSTOMER][NEUTRAL] Yeah, they didn't, yeah, I don't know why they, they did it wrong, but
[CUSTOMER][NEGATIVE] I don't know why they have it as $175 because it's $70 it's not $175 and so that's just weird.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEGATIVE] They didn't cover it. They just said the patient is liable for the allowed amount that we allow, which is, it don't even match what's on the UOB, so OK.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] And and [PII], do y'all give reference numbers?
[AGENT][NEUTRAL] Yes, my name is [PII]. The [PII], and we're gonna use that today's date as a reference. Now, do we have any other claims for this individual that we need to look up or?
[CUSTOMER][NEUTRAL] is.
[CUSTOMER][NEUTRAL] that
[CUSTOMER][POSITIVE] No, that's all, but I appreciate your help.
[AGENT][POSITIVE] OK, well thank you for contacting UP have a good day.
[CUSTOMER][NEUTRAL] OK.