AccountId: 011433970860
ContactId: dec2eb16-4eb5-40bb-b623-224f071cf88d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 924039 ms
Total Talk Time (AGENT): 313941 ms
Total Talk Time (CUSTOMER): 243625 ms
Interruptions: 1
Overall Sentiment: AGENT=0.1, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/09/dec2eb16-4eb5-40bb-b623-224f071cf88d_20250509T14:48_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] [PII], my name is [PII]. I am calling from the provider's office. I have a claim that I need to see if you can look at, please.
[AGENT][NEUTRAL] OK, I can help you, [PII]. What's the policy number?
[CUSTOMER][NEUTRAL] It is.
[CUSTOMER][NEUTRAL] 01279925
[AGENT][NEUTRAL] Uh huh and I get phone number in case we're disconnected?
[CUSTOMER][NEUTRAL] My direct phone number is [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] Give me one moment.
[AGENT][NEUTRAL] Want to verify the patient's name and date of birth for me?
[CUSTOMER][NEUTRAL] Well, I'm really confused. Um, I have the patient's name is [PII]. His date of birth is [PII]. Um, I have, um,
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The policyholder is [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And I have on the remit, it's [PII]. So I'm not sure if the patient's last name is [PII] or [PII].
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] It's [PII].
[CUSTOMER][NEUTRAL] OK, all right. So, all right, I'm OK. I was like, I'm looking, I'm like, OK, OK, so.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes, uh, we build the claim data service 828 of 24.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] The only thing I have is a duplicate denial. I don't have, uh, from the original billing, uh, it looks like we billed it on [PII] uh electronically and then we rebuild the paper claim and the paper claim I think is the one that denied as a duplicate, but I don't have anything from the original billing.
[AGENT][NEUTRAL] And are you calling from a dental office or medical?
[CUSTOMER][NEUTRAL] Medical
[AGENT][NEUTRAL] OK, so that's a dental policy number that you provided. Let me see. The medical the me
[CUSTOMER][NEUTRAL] Well, that might be what.
[AGENT][NEUTRAL] Mhm. Yeah. The medical policy number is 012.
[AGENT][NEUTRAL] 88.
[AGENT][NEUTRAL] 297.
[CUSTOMER][NEUTRAL] So do you have a claim on file at all for us?
[AGENT][NEUTRAL] Mhm, I'm pulling up the policy to see.
[CUSTOMER][NEUTRAL] OK. OK.
[AGENT][NEUTRAL] And you said [PII].
[CUSTOMER][NEUTRAL] Mhm. $5,691.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Under this policy, I have his last name as [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And you said on the explanation of benefits you're showing the other last name?
[CUSTOMER][NEUTRAL] It shows the insured is [PII]. Uh, it shows claimant [PII].
[AGENT][NEUTRAL] Which is true.
[AGENT][NEUTRAL] OK, OK.
[AGENT][NEUTRAL] And let's see.
[AGENT][NEUTRAL] And the explanation of benefits that you received, what's the claim number for that one?
[CUSTOMER][NEUTRAL] Um, 3553954.
[AGENT][NEUTRAL] And this would be the duplicate you said?
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And was this for an emergency room visit?
[AGENT][NEUTRAL] Or was it for surgery? OK.
[CUSTOMER][NEUTRAL] Yes it is.
[CUSTOMER][NEUTRAL] Um, well, he, it looks like he broke a body part, left radius, struck by football, um, didn't have surgery. So, um, but he did have a treatment, a fracture, so.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I think that is probably a surgical code.
[CUSTOMER][NEUTRAL] Not sure.
[AGENT][NEUTRAL] OK, so is it a 99284 and a 25605 on the claim?
[CUSTOMER][NEUTRAL] Yes, it is. Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] What are the two modifiers for each of those codes?
[CUSTOMER][NEUTRAL] We have a 25 on the charge 99284 and a 54 on the 25605.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right, so this was actually processed under the accident policy, which is a different policy number, and I'm gonna go back to the medical cause it looks like an office visit benefit was paid on that one, but the accident policy number is 1288298.
[AGENT][NEUTRAL] And I do see the claim number that denied us a duplicate 3553954 that you provided and so the original claim, let's see.
[AGENT][NEUTRAL] What's the name of the hospital or is this the professional fee?
[CUSTOMER][NEUTRAL] It's the professional fee but it's um ACS primary care physician Southeast is the group that my provider is with.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I see that claim. Did you receive a payment?
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] OK, so the claim number for the ER physician's charge is 35, the claim number is 3511053. That's the original claim.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And it made a payment of 500.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Let's see, verify if it's cleared.
[AGENT][NEUTRAL] That was processed on [PII].
[CUSTOMER][NEUTRAL] $500 even.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Which is the maximum.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] And if I can get you to verify the billing address?
[CUSTOMER][NEUTRAL] The pay to address is [PII].
[AGENT][NEUTRAL] OK, and that's the address the check was mailed to, but we do currently show it outstanding, so what we can do on our end is, uh, verify if the check is cleared um if it has not, uh, we could request that it be voided and then a new one reissued to [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And I did give you.
[CUSTOMER][NEUTRAL] And you said payment was issued.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] On
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And I did give you the claim number, right?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes, 351-105-3.
[AGENT][NEUTRAL] Right, now, let me go back to the.
[CUSTOMER][NEUTRAL] So, let me ask you this.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] So it maximum benefit is $500 does that come with a provider discount or is the balance the patient responsibility?
[AGENT][NEUTRAL] OK, so we do not determine patients responsibility, um, on the explanation it says that this is the maximum benefit, uh, for this service and so he's exhausted the benefit.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] That's it. Mhm.
[CUSTOMER][NEUTRAL] OK, so that would be patient mobility.
[AGENT][NEUTRAL] Yeah, and then let me go back to the HI policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Is this an insurance that they choose to take out? Because I'm, I think I'm it's not very good.
[AGENT][NEUTRAL] Yeah, it's through their employer it's through their employer.
[CUSTOMER][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] Well, we all know how that goes.
[AGENT][NEUTRAL] Exactly, let me see.
[CUSTOMER][NEUTRAL] That's why I don't go to the doctor.
[AGENT][NEUTRAL] 2
[CUSTOMER][NEGATIVE] And that's something you work in healthcare and you can't afford to go to the doctor.
[AGENT][NEUTRAL] I know.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] It affects us all
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, and so for the surgical charge 25605 under the hospital indemnity policy, um, which is a medical policy, it looks like a payment of 158.20 was issued. Um, did you receive that check?
[CUSTOMER][NEUTRAL] Now
[CUSTOMER][NEUTRAL] We have nothing. That's why I'm that's why I'm calling. I'm like.
[AGENT][NEGATIVE] OK, OK, you've not received anything. Yeah.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] ACS primary care physician self. That's not you though, is it?
[AGENT][NEUTRAL] That's a different
[CUSTOMER][NEUTRAL] Yes, that's it, that's uh Southend.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So this was mailed to the same [PII], so we'll verify this is outstanding is what I'm saying and so we can also check to verify if this one has been cashed. If not, we'll proceed um with getting permission to have it um reissued a new check issued.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, good deal.
[AGENT][NEUTRAL] OK, and the HI policy number.
[AGENT][NEUTRAL] Is if I haven't given it to you already, I think I may have 1288297.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK, so the 128.158.20 payment was issued under the HI policy and the accident policy paid 500.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So that may take care of some of the balance that he owes the 12,850.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] So, uh, we'll proceed with the next step and then um I will give you a call back at the number you provided. Is this your direct line? [PII]?
[CUSTOMER][NEUTRAL] Yes, it is.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Uh-huh, [PII].
[AGENT][NEUTRAL] OK, glad I verified that. Is that your direct line?
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK, I'll call you back uh once we get a word from our finance team.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] All righty. Any other questions, [PII]?
[CUSTOMER][NEUTRAL] Um, do you offer a call reference number?
[AGENT][NEUTRAL] Uh, not a number per se.
[CUSTOMER][NEUTRAL] Or is it just your name and today's state?
[AGENT][NEUTRAL] You can use my name in today's dates reference for your for our call today [PII]
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then first initial last name is [PII].
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] Or [PII]
[AGENT][POSITIVE] Exactly, I just got that.
[CUSTOMER][NEUTRAL] That's my name.
[AGENT][NEUTRAL] All right.
[CUSTOMER][POSITIVE] OK. Thank you so much. I do appreciate your help in this.
[AGENT][POSITIVE] Oh, you're welcome and thanks for calling APL. Have a good day.
[CUSTOMER][NEUTRAL] Uh-huh. All right, bye-bye.
[AGENT][NEUTRAL] Bye bye.