AccountId: 011433970860
ContactId: f5ab56bb-d638-4281-bf7a-0266311e5281
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 711909 ms
Total Talk Time (AGENT): 426181 ms
Total Talk Time (CUSTOMER): 327421 ms
Interruptions: 12
Overall Sentiment: AGENT=0.6, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/09/f5ab56bb-d638-4281-bf7a-0266311e5281_20250609T13:50_UTC.wav
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[AGENT][POSITIVE] Thank you for calling American Public Life. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Uh, hi [PII], good morning. um, I, uh, called a little while ago. I was, uh, discussing a claim with someone and, um, I just, they told me to call the provider. It was about an overpayment.
[AGENT][POSITIVE] Good morning.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, you, you guys paid the provider, um, but the provider had incorrectly billed it initially, so, um, my primary insurance covered 100%, so, um, the money needs to come back from the provider back to the American public.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So I and I just the provider said that you guys have to initiate the request for overpayment so.
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] OK, so have we, we don't normally initiate that unless either the provider normally sends in the updated uh explanation of benefits. So.
[AGENT][NEUTRAL] Is it, did they know that they have been paid at 100%?
[CUSTOMER][NEUTRAL] OK, well, is it just because
[AGENT][NEUTRAL] The provider is aware.
[CUSTOMER][NEGATIVE] Uh, well, I just called the, the provider just said that yeah the bill was paid 100% uh by Aetna, which was my primary, um, so yeah, and then, uh, there's, uh, I just don't wanna I know American public sent them $353 that they're not entitled to, so I don't want them them to keep that.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK, let me take a look at your policy. Right, um, yeah, we providers are the, the process when a claim has been overpaid. Now, if we see a claim that we actually paid uh in error, maybe to the wrong provider or overpaid a claim, we do reach out and ask for a refund.
[CUSTOMER][NEUTRAL] Uh yeah
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] like
[AGENT][NEUTRAL] In the situation where um maybe they send us an explanation of benefits uh showing you owe you, you know, you owe that amount and then the primary goes back and or pays it at 100%, then that provider sends us the EOB showing that Aetna paid it at 100% and then we, at that point, we will initiate a ref you know, a refund request. Now what you can do.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I submit, do you have a copy of your explanation of benefits?
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] Uh, yes, I do have the EOB from Aetna, um, and it does show that the for that date of service that it was paid 100%.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so you can definitely uh send that explanation of benefits in, uh, letting us know this claim was paid in full by your primary, and at that point, we will initiate the refund request. But without like any documentation, we can't just say, OK, hey, we're gonna reach out and ask for money back when we don't have any documentation showing anything different than what we received.
[CUSTOMER][NEUTRAL] My share is 0.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] OK, um, alright, so how do I get this, uh, EOB to you guys?
[AGENT][NEUTRAL] OK, let me get your policy pulled up really quick. I'm sorry, I just rambled on. Uh, what is your policy number?
[CUSTOMER][NEUTRAL] Uh, sure.
[CUSTOMER][NEUTRAL] Uh, policy number 00964681.
[AGENT][NEUTRAL] OK, and let's see, Mr. [PII], if you could verify your date of birth.
[CUSTOMER][NEUTRAL] Uh, yeah, [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Thank you for verifying that information and let's see and so in which claim do you have a claim number in question?
[CUSTOMER][NEUTRAL] 5.
[CUSTOMER][NEUTRAL] It is, uh, I have the the date of service is [PII].
[CUSTOMER][NEUTRAL] Uh, claim number, do I have the claim number.
[CUSTOMER][NEUTRAL] Or.
[AGENT][NEUTRAL] OK, is this one for the facility where we pay 35343?
[CUSTOMER][NEUTRAL] Correct, yeah, they had initially had built billed it as a uh hospital stay instead of as an urgent care.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And so it, it applied, you know, they, it was my deductible and whatever so and then you guys paid the 353 and then we had it reprocessed so.
[AGENT][NEUTRAL] OK, yeah. And this, OK. So, see, in this instance, if there's even a correction in
[AGENT][NEUTRAL] In their claim, so the claim should have been urgent care and they built this facility.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] OK, is that and, and then they sent the claim back like a corrected claim and the claim was then paid in full?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] OK. So, yeah, see, they, they should really send us.
[AGENT][NEUTRAL] Uh, the corrected claim with the explanation of benefits.
[AGENT][NEUTRAL] Uh, so we even document it correctly in our system. I'm not sure if maybe who you spoke with was not aware of what that process normally is. Uh, so when did your primary make that, uh, additional payment?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Or make the payment to them.
[CUSTOMER][NEUTRAL] Uh, the EOB, yeah, the EOB is dated [PII], so maybe it's just not enough time. It's only it's been a couple of weeks.
[AGENT][NEUTRAL] Yeah, they, yeah, they may, uh, they not, like I said, that's what the providers do. So if they sent in the correction, received an updated EOB they still file it again to the secondary, so we can make our adjustments and then they base that um sometimes they'll send the uh updated EOB and just go ahead and send the refund.
[AGENT][NEUTRAL] And then sometimes they'll send just the updated information and then leave it up to us to request a refund, but they, yeah, that's the normal process, um, it's not, oh, they have to ask us because we're not going to get the EOB unless we get it from the the provider, so we don't know that payment's been made.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So I'm wondering if they, they're not aware of it, but.
[CUSTOMER][NEUTRAL] OK, all right now.
[AGENT][NEUTRAL] You know, whoever you spoke to, they're not maybe aware of the process.
[CUSTOMER][NEUTRAL] Yeah, I mean, I just, I just someone in in their billing office and they basically they told me that I had to call you. So now if I send you the EOB, can I send you the EOB and then you guys can initiate it or?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] You can. Yeah, you can send the EOB um and we can initiate, um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I believe, let me, let me speak. Yeah, so you can, uh, we can't take it by email, so your options are to mail it in, fax it, or you can upload it to the online service center.
[CUSTOMER][NEUTRAL] OK, so what do I email that uh or?
[CUSTOMER][NEUTRAL] OK, oh I can upload it. I'm actually logged into the online. How would I do that?
[AGENT][NEUTRAL] Right, and so. So have you uh ever used the online service center?
[CUSTOMER][NEUTRAL] Uh, I just got into it today with, uh, with the help of the other agent I spoke with. Um, it's a little different.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK, perfect. OK. So you.
[AGENT][NEUTRAL] Um, OK. So what you can when you go online, you'll look for to, um, the option to file a claim.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] File a claim, start a claim, yes.
[AGENT][NEUTRAL] You're gonna upload it as though you're, yes, so that is, you'll start that process, um, and then it'll allow you, once you go through the steps, it will allow you to upload documents and you just upload a copy of the uh explanation of benefits before you upload it, you can write or you can type up a letter, uh, you know, this is in reference to claim.
[AGENT][NEUTRAL] 3602663, uh primary reprocessed claim and paid in full, please request refund.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, got it. Alright, perfect, yep, I'm, I'm there now where I can, uh, drop a file in, uh, with the PDF, um, yep, so full, so statement dated now these EOBs I get from Aetna are a little strange because they have multiple, um, they have multiple claims on them.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so
[CUSTOMER][NEUTRAL] Right, you guys can look at it and you can determine from there.
[AGENT][NEUTRAL] Yeah, so what you can do is, yeah, you can shorten that. I don't know how many pages it shows, but you can just, um, you only have to send us where you see the actual claim that was reprocessed or, you know, if you have to send all of it, you can mark out all of the other dates to make sure we just focus on that particular, particular date because what I, what I do know is
[CUSTOMER][NEUTRAL] Uh, got it.
[AGENT][NEUTRAL] Whatever you send, we have to address. So you, if we see other dates on there, we're going to process those other dates. So you'll get a lot of denials or, you know, so yeah.
[CUSTOMER][NEUTRAL] Uh, got it.
[CUSTOMER][NEUTRAL] Yeah, alright, so I can just redact anything that doesn't apply to this, so.
[AGENT][POSITIVE] Correct, yes, sir.
[CUSTOMER][NEUTRAL] OK, alright, perfect. Uh, alright, I know I have to clean up the file a little bit.
[AGENT][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] All right.
[AGENT][NEUTRAL] OK. Is there anything else I can help you with?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][POSITIVE] No, that was it thank you so much um and uh yeah.
[AGENT][NEUTRAL] Uh-huh. You're welcome, Mr. [PII].
[CUSTOMER][POSITIVE] I, uh appreciate it, um.
[CUSTOMER][NEUTRAL] Let me see, oh, you know what, actually I have another one. The, yeah, I have another question because, uh, I was trying to get an answer. Um, the, my wife's been going to, uh, physical therapy, um, and the claims were being paid by American public, the co-pays were being paid.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, they now told her that they've exhausted all of the, all of the claim, all of the benefits.
[AGENT][NEUTRAL] Uh, yeah, OK, I see that here.
[CUSTOMER][NEUTRAL] Um, but yeah, do you know what, what is the benefit that I have for physical therapy visits?
[AGENT][NEUTRAL] OK, let's see. Please advise verifying benefits.
[CUSTOMER][NEUTRAL] I thought we had up to $1000.
[AGENT][NEUTRAL] OK. OK. So, let's see. Please be advised verifying benefits is not guaranteed payment. Um, so physical therapy is covered under outpatient. For your outpatient, you have $500 a calendar year to use towards outpatient services. The $1000 is for uh inpatient if you are admitted into the hospital.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] Alright, so outpatient.
[AGENT][NEUTRAL] So I do show she did exhaust her $500 for the calendar year.
[CUSTOMER][NEUTRAL] OK, alright, do you have a, is it possible to get like a list of all the visits that were paid under that $500?
[AGENT][NEUTRAL] Uh, you can, yes, so you can actually, uh, through the online service center pull those uh documents up for [PII].
[AGENT][POSITIVE] And it'll show everything paid out uh.
[CUSTOMER][NEUTRAL] Uh, I
[AGENT][NEUTRAL] Under your wife.
[CUSTOMER][NEGATIVE] I didn't see a way to do that. It was, uh, it's no longer doesn't allow you to download anything or even get the EOBs, um, when I go to claims.
[CUSTOMER][NEGATIVE] Doesn't seem to have an option for that.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] OK. Mm, I'm not sure why you wouldn't be able to do that.
[CUSTOMER][NEUTRAL] I know you guys are on a new portal now so.
[AGENT][NEUTRAL] Yeah, I don't, yeah, OK. I haven't heard that that's an issue, but, uh, so what I can do is put in a request to have those EOBs pulled and then they will, uh, they can um mail them out to you.
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Ah, OK, alright, yeah, I mean, I know I normally do get the EOBs, but there's just I get so many, so I don't know if I, I don't know if I've kept all of them, so I just, uh, I wanna kind of go over it and make sure that everything's being billed properly so.
[AGENT][NEUTRAL] Mhm, I understand.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Correctly. OK, no problem. I can uh put that request in and ask that all claims for [PII] for your wife be the EOB to be mailed to you.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] OK, that'd be great thank you so much.
[AGENT][POSITIVE] You're welcome. You have a wonderful day. Thank you for calling APL.
[CUSTOMER][POSITIVE] Thank you, you, you too bye bye.
[AGENT][NEUTRAL] Bye bye.