AccountId: 011433970860
ContactId: f07c9128-af1f-48b9-a537-f67225a558ac
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 651469 ms
Total Talk Time (AGENT): 283237 ms
Total Talk Time (CUSTOMER): 204063 ms
Interruptions: 1
Overall Sentiment: AGENT=0.4, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/17/f07c9128-af1f-48b9-a537-f67225a558ac_20250117T21:10_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] And uh, my name is [PII] and I'm calling from a dental office. Just have a question about a claim please.
[AGENT][NEUTRAL] OK, I can help you with the claim. And [PII], may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you for that. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] Um, policy number is 02559940.
[AGENT][POSITIVE] Thank you. Hold on one moment.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][NEUTRAL] Thank you, and all the information provided is a verification of benefits, not a guarantee of payment. And how may I assist you with the claim?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] On the claim, uh, for [PII], they did not pay on the [PII]. Can you tell me why?
[AGENT][NEUTRAL] Mhm, let's see [PII].
[CUSTOMER][NEUTRAL] That was her first visit with our facility, so.
[AGENT][NEUTRAL] [PII]. OK, here it is. Hold on one moment, let me see what this code is.
[CUSTOMER][NEUTRAL] Fluoride treatment.
[AGENT][NEUTRAL] Um, so it says the benefit does not, I'm sorry, the policy does not provide benefits for any procedure or service not listed in the schedule of benefits.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me see.
[CUSTOMER][POSITIVE] Alrighty, uh.
[AGENT][NEUTRAL] So it's the coding that was used. Do you have a copy of their fax back?
[CUSTOMER][NEUTRAL] Their faxed back like who's?
[AGENT][NEUTRAL] The patients.
[CUSTOMER][NEUTRAL] What do you
[CUSTOMER][NEUTRAL] Uh, yes, I do. I have the one that we got from our our facility.
[AGENT][NEUTRAL] No, no, I mean, do you have a copy from APL because the coding, I mean, fluoride is on here, but it's not, there's not a 1206 code.
[CUSTOMER][NEUTRAL] OK, so I've got the claim right in front of me they're EOB, is that what you're wanting?
[AGENT][NEUTRAL] No, no. So we have like their schedule of benefits like with the calendar year max, there's a list of covered codes.
[CUSTOMER][NEUTRAL] Let me see.
[AGENT][NEUTRAL] That's on here as well. Um, I'm just asking, do you have a copy? If not, I can send it to you.
[CUSTOMER][POSITIVE] Uh, no, I don't, but I would appreciate you sending it to me, yes.
[AGENT][NEUTRAL] Sure, what's a good fax number for you?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK. And do I need to put attention on [PII]?
[CUSTOMER][NEUTRAL] No, uh uh, you don't have to put that it's coming right towards it.
[AGENT][NEUTRAL] OK, and it's [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] All right, so I'm sending this over to you now.
[CUSTOMER][NEUTRAL] OK, and this $4 patient responsibility is that just their co-payment?
[AGENT][NEUTRAL] Um, let me see if it shows. Hold on one moment.
[CUSTOMER][NEUTRAL] Or do you show us out of network or what is that?
[AGENT][NEGATIVE] No, it doesn't show.
[CUSTOMER][NEUTRAL] Said patient responsibility for.
[AGENT][NEUTRAL] It's not like a co-pay, it's just the difference between the $80 and the $76 that was paid and then the $60 and the $56 that was paid.
[CUSTOMER][NEUTRAL] OK, so patient responsibility is $58 is that right?
[AGENT][NEUTRAL] Hold on, let me pull up the EOB. Hold on one moment.
[AGENT][NEUTRAL] Yes, patient responsibility 50 and then the 4, yes, 58, yes.
[CUSTOMER][NEUTRAL] OK, so, um.
[CUSTOMER][NEUTRAL] Do you show us in or out of network or do y'all have network?
[AGENT][NEUTRAL] Um, this policy does have the um Carrington PPO network, but the benefits are the same whether you're in or out of network. If you're out, you just, the patient just wouldn't get an additional percentage of the balance, but the benefits are the same.
[CUSTOMER][NEUTRAL] OK, so they did not get an additional percentage off, is that correct?
[AGENT][NEUTRAL] I don't see that. Um, are you a Carrington provider?
[CUSTOMER][NEUTRAL] I believe so. Can you check?
[AGENT][NEUTRAL] There's no way for me to check. Um, Carrington is a different, um, company, but are you trying to see if that's where the $4 is coming from? I can ask someone in claims.
[CUSTOMER][NEUTRAL] I was gonna ask if the $4 should should not have been a contractual write off.
[CUSTOMER][NEUTRAL] Because it has charge and then scheduled is $56.
[CUSTOMER][NEGATIVE] And it paid $56 which is 100%, so why would the patient be paying $4?
[AGENT][NEUTRAL] Hold on 1 2nd.
[AGENT][NEUTRAL] So I'll ask claims that question. Do you mind if I place you on just a brief hold?
[CUSTOMER][NEUTRAL] I do not mind.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEGATIVE] This is why claims needs to process and take their claims calls because this is a waste of time.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Ferring
[AGENT][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] It's [PII]. May I help you?
[AGENT][NEUTRAL] Hey, [PII], this is [PII] on the care team. How are you?
[CUSTOMER][POSITIVE] I'm good how are you?
[AGENT][NEUTRAL] I'm OK. I just have a provider on the other line that's asking a lot of questions about this explanation of benefits. Can you look at this for me? I just want to know if, if I'm explaining this correctly.
[CUSTOMER][NEUTRAL] OK, do you have the claim number?
[AGENT][NEUTRAL] Mhm. It is, oh wait, that's the policy number, um 353-571-9.
[CUSTOMER][NEUTRAL] What's the name?
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] The patient is [PII].
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] I was just wondering if it was the lady I talked to this morning.
[CUSTOMER][NEUTRAL] Oh, this is on a dental?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, and what are they asking?
[AGENT][NEUTRAL] So, on the explanation of benefits, she's [PII]ng this patient responsibility uh column.
[AGENT][NEUTRAL] If this is saying this is what the patient owes, or was that what the, that was just the patient's responsibility of the 60?
[AGENT][NEUTRAL] But we paid everything that was scheduled.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Yeah, we don't cover the uh 1206 procedure.
[CUSTOMER][NEUTRAL] So he, she's responsible of 50. Why I got 58, let's see, hold on, OK, because they charged 60.
[CUSTOMER][NEUTRAL] You only pay 56. Yeah, patient owes 58, so that would be what the patient would owe them.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So because she's saying, OK, wait a minute.
[AGENT][NEUTRAL] So the 4, so the patient responsibility column is what is owed, is what the patient owes, the $58.
[CUSTOMER][NEUTRAL] Right. Uh-huh.
[AGENT][NEUTRAL] OK, so she, she asked me if it was scheduled at 56 and it covered at 100 and we paid 56. The 4 is the difference between the 56 and the 60.
[CUSTOMER][NEUTRAL] I don't know what she talking about.
[AGENT][NEUTRAL] And the 7 because I thought I said the the $4 is the difference because it was charged $60 and we paid $56 which is what was scheduled, right?
[CUSTOMER][NEUTRAL] Yeah, just go line by line with her say the $1206 you charge $50 we don't cover it at all, so that's for $50.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The 272 is 60.
[CUSTOMER][NEUTRAL] The schedule of benefits is 56.
[CUSTOMER][NEUTRAL] So she would owe that $4.
[AGENT][NEUTRAL] Oh, the schedule of benefits is what we'll pay for that. OK, I got it. OK.
[CUSTOMER][NEUTRAL] Well we pay, right, mhm, and then the 80 we in the schedule 76 and we paid 76 so she's responsible for 58.
[AGENT][POSITIVE] Do, OK, I got it. Thank you.
[CUSTOMER][NEUTRAL] Mhm. OK. You're welcome.
[AGENT][NEUTRAL] All right, bye-bye.
[CUSTOMER][NEUTRAL] Bye bye.
[AGENT][NEUTRAL] Hello [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Thank you so much for holding. I apologize for that wait. So, on the explanation of benefits, the charge column.
[AGENT][NEUTRAL] That's the total that was charged for each line. So for the
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, $272 was charged $60 but our schedule of benefits says we only pay $56. So that $4 is the difference between the $80 and the 76, the $60 and the 56, and then we don't cover 1206 at all, so that's that $50. So the patient is $58.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alrighty, OK, and I haven't gotten that fax back yet, so still waiting on it.
[AGENT][NEUTRAL] Oh, hold on, I haven't sent it. Let me send it to you. Hold on one second.
[CUSTOMER][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] I started looking at that. Hold on one moment.
[CUSTOMER][NEUTRAL] I interrupted you.
[AGENT][NEUTRAL] OK, here we go.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, so I just sent it over to you.
[CUSTOMER][POSITIVE] OK, alrighty, I'll be waiting for it.
[AGENT][NEUTRAL] All right, well, was there anything else I could assist you with today?
[CUSTOMER][POSITIVE] No ma'am thank you so much.
[AGENT][POSITIVE] You're welcome. Well, thanks for calling APL. I hope you have a great weekend.
[CUSTOMER][POSITIVE] You too thank you bye bye.
[AGENT][POSITIVE] Thank you. Bye bye.