AccountId: 011433970860
ContactId: fc8d2dd9-ea47-4ab3-b544-0d19964a9a68
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 530500 ms
Total Talk Time (AGENT): 219511 ms
Total Talk Time (CUSTOMER): 161880 ms
Interruptions: 2
Overall Sentiment: AGENT=0.8, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/20/fc8d2dd9-ea47-4ab3-b544-0d19964a9a68_20250220T16:34_UTC.wav
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[AGENT][POSITIVE] Good morning thank you for calling
[AGENT][NEUTRAL] Hello, my name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII] calling from Ortho Lone Star. Got a question in regards to a payment we received on a member.
[AGENT][POSITIVE] It would be my pleasure.
[CUSTOMER][NEUTRAL] Because it was an overpayment
[AGENT][POSITIVE] Alright, it would be my pleasure to assist you, [PII]. What is a call back?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] Thank you, [PII]. What is the pol uh, do you have a claim number or policy number, either one?
[CUSTOMER][NEUTRAL] I have the claim number.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It's 354-774-1.
[AGENT][NEUTRAL] And what is the patience
[AGENT][NEUTRAL] Date of birth, please?
[CUSTOMER][NEUTRAL] It's [PII] and his date of birth is.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Alright, thank you. This is for data service 1122 24 for Ortho Lone Star. OK, and you said this is an overpayment?
[CUSTOMER][NEUTRAL] Yeah, the, um, of $10.35 on the procedure code J 3301, his primary insurance paid that amount in full.
[CUSTOMER][NEGATIVE] With no responsibility to the patient.
[CUSTOMER][NEUTRAL] And APL paid the $10.35.
[AGENT][NEUTRAL] OK. Bear with me just one moment. I'm trying to get that information pulled up.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] It may take me just a minute so my computer is.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] today, so bear with me.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] I do.
[AGENT][NEUTRAL] Instead of making you hold and wait.
[AGENT][NEUTRAL] representative that can pull up and check it for you OK?
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you, [PII]. One moment.
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hi [PII], it's [PII]. How are you doing this morning?
[CUSTOMER][NEUTRAL] Fine, how are you?
[AGENT][NEUTRAL] I'm doing fine, just.
[AGENT][NEGATIVE] computer issues.
[AGENT][NEGATIVE] I have a provider on the line that's stating that there's no for payment on a claim and I cannot get my own base to be nice.
[CUSTOMER][NEUTRAL] What's the you know the policy number?
[AGENT][NEUTRAL] Oh yeah, yeah, yeah, I'm sorry. I, I'm still trying to get it to come up and it's still not coming up. It's 1896415 for [PII] Fielding, claim number 354.
[CUSTOMER][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] 7741.
[AGENT][NEUTRAL] And she's stating that we overpaid on the CPTJ 3301.
[CUSTOMER][NEUTRAL] OK, let me get it pulled up here. Let's see.
[AGENT][POSITIVE] I hope your is nicer than mine.
[CUSTOMER][NEGATIVE] Oh, you break, you breaking in and out.
[CUSTOMER][NEUTRAL] You're choppy.
[AGENT][NEUTRAL] Am I choppy must be the internet.
[CUSTOMER][NEGATIVE] Not right now you're not.
[CUSTOMER][NEUTRAL] Let's see. Well, the EOB has $10.35.
[CUSTOMER][NEUTRAL] Let's see, let me keep looking.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Yeah, that was the correct amount based off the EOB received 1035 for that code.
[AGENT][NEUTRAL] So we need an updated EOB.
[CUSTOMER][NEUTRAL] Yeah, mhm, cause the total out of pocket applied towards their deductible and co-pay was $110.28 and that's the amount that was paid.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yep, so we would need an updated EOV.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yep.
[AGENT][NEUTRAL] I can get, I can just get back to her and tell her according to what the information we received we played paid the claim correctly and and she she can fax updated EOP.
[CUSTOMER][POSITIVE] That works.
[AGENT][NEUTRAL] As long as it doesn't get denied as a duplicate.
[AGENT][NEUTRAL] Which could happen
[AGENT][NEGATIVE] Unfortunately.
[CUSTOMER][NEGATIVE] Yeah, unfortunately.
[AGENT][NEUTRAL] Alright, I'll just tell her to um fax that over to us so we can get that refund.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Allocated for that overpay. Thank you, [PII]. I appreciate you. Have a great day.
[CUSTOMER][POSITIVE] You're welcome anytime. You too.
[AGENT][POSITIVE] Thank you. Bye-bye.
[CUSTOMER][NEUTRAL] Bye.
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][POSITIVE] Thank you for your patience. It's [PII] again. I spoke with the claims adjuster and she was able to pull it up and according to the EOB that we received with the claim, it does have that $10.35.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] On that EOB with the claim. Now if the primary went back and reprocessed, all you have to do is fax in that.
[AGENT][NEUTRAL] Um, updated EOB.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Well, let's see now we've all let me.
[AGENT][NEUTRAL] And we can get that refund allocated.
[CUSTOMER][NEUTRAL] Let me see.
[CUSTOMER][NEUTRAL] Because they paid the 10:35.
[CUSTOMER][NEUTRAL] But we've only sent one claim to them to show where they paid the 1035.
[AGENT][NEUTRAL] With the EOP that we received with the claim it did have that 1035 applied to.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] The J 3301.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And we just need to resubmit the claim with the ELB showing where Blue Cross and Blue Shield has showed paid it.
[AGENT][NEUTRAL] Yeah, so
[AGENT][POSITIVE] You don't even have to resubmit the claim. You can actually fax the updated it directly to our claims department.
[AGENT][NEUTRAL] And just put um I can give you the
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Reference in the claim number that you give me.
[AGENT][NEUTRAL] Say overpayment was made on CPT 33301 and they'll get that to our refund department.
[CUSTOMER][NEUTRAL] Mhm. Yeah.
[AGENT][NEUTRAL] Or we they'll get that and we'll request a formal refund for 10:35.
[CUSTOMER][NEUTRAL] OK, yeah, because
[CUSTOMER][NEGATIVE] refund.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, because he's got one more data service that the same thing happened to yeah, OK, so what's the fax number?
[AGENT][NEUTRAL] The fax number to our claims department is 877.
[CUSTOMER][NEUTRAL] Huh?
[AGENT][NEUTRAL] 365.
[CUSTOMER][NEUTRAL] Hm
[AGENT][NEUTRAL] 942 3.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So we just need to fax the EOB.
[AGENT][NEUTRAL] Yeah, and just reference that claim number the.
[CUSTOMER][NEUTRAL] With the with the claim number, OK.
[AGENT][POSITIVE] That's right.
[AGENT][NEUTRAL] And then we'll get that refund request sent out, the formal refund request.
[CUSTOMER][POSITIVE] OK, alright, [PII], if I just get the initial to your last name and reference number and I'll get this faxed over. I appreciate it.
[AGENT][NEUTRAL] Sure. The initial to my last name is [PII].
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] And the reference number would be my name and today's date.
[CUSTOMER][POSITIVE] OK, I appreciate you taking the time to check on that for me and giving me the information.
[AGENT][NEUTRAL] Oh
[AGENT][POSITIVE] My pleasure and thank you for your patience on my computer.
[AGENT][POSITIVE] And I hope you have, I hope you have a wonderful day.
[CUSTOMER][NEUTRAL] Yeah, that's OK.
[CUSTOMER][POSITIVE] You too. Thank you. Bye bye.
[AGENT][NEUTRAL] Bye-bye.