AccountId: 011433970860
ContactId: 005bbe52-35b0-4a2a-92dd-5e1d74cdea4c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 632679 ms
Total Talk Time (AGENT): 354662 ms
Total Talk Time (CUSTOMER): 223205 ms
Interruptions: 1
Overall Sentiment: AGENT=0.5, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/29/005bbe52-35b0-4a2a-92dd-5e1d74cdea4c_20250429T21:56_UTC.wav
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[AGENT][NEUTRAL] For contacting ATO. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, um, I'm calling cause, uh, I submitted a claim, uh, a few weeks ago, uh, for, um, a surgery that I had.
[CUSTOMER][NEUTRAL] Um, and then they sent me back some paperwork that I I needed to fill up.
[CUSTOMER][NEUTRAL] Um, about, it says that they uh they received the claim, uh, but in order to provide further consideration, uh, they need supporting, uh, documentation, uh, to evidence the accident.
[CUSTOMER][NEUTRAL] I mean, super documentation by include but I was, uh, out of my bills, uh, diagnosis codes, super bills, office notes, hospital admissions, and discharge summaries. So, um, I was going over a document and I sent, I uploaded, uh, a few, uh, evidence, so I don't know how it is, uh, that's enough because I haven't heard back from the company that.
[AGENT][NEUTRAL] Well, let's look at your, let's look at your um claims. Uh, what is your policy number, please?
[CUSTOMER][NEUTRAL] Sure
[CUSTOMER][NEUTRAL] It is 02486912.
[AGENT][NEUTRAL] Thank you. And if I could verify your name, uh date of birth, and a phone number, please.
[CUSTOMER][NEUTRAL] Sure. It is [PII]. Uh, date of birth is uh [PII], and my phone number will be [PII].
[AGENT][POSITIVE] OK, I appreciate that. Let's see what we have here.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I see.
[AGENT][NEUTRAL] So, it looks like there was an outpatient um
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] Diagnostic procedure for uh uh [PII]. uh the provider is [PII].
[AGENT][NEUTRAL] And uh let's what we have here.
[AGENT][NEUTRAL] Looking at the other things. There's also a facility bill for um uh Homestead Hospital.
[AGENT][NEUTRAL] As well as surgery, uh, the surgery that was done. Uh, this is on [PII], OK.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] So what we're, we are looking for, um, did you say that you just uploaded something because I, I don't see it if you did.
[CUSTOMER][NEUTRAL] No, it, no, I upload a few uh documents. Those are pretty much the bills, uh, the hospitals is, um.
[CUSTOMER][NEUTRAL] Sending to my, my insurance, um.
[CUSTOMER][NEUTRAL] So that's, that's all the evidence that I, I mean, I have, they asked me, uh, my insurance asked me to um create some sort of uh accident uh evidence, so I don't know if that's also.
[CUSTOMER][NEUTRAL] Um, something that I cannot know. They asked me about how was the accent and if it was work related or it was uh practicing sports, and I asked a couple of questions about that and submitted to them.
[CUSTOMER][NEUTRAL] I don't know if that counts as a a.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Well, what, what we're looking for, uh, there, there are actually two things that we're looking for. Um, first of all, uh, you have AvMed as your, as your primary insurance. Is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, so for each date of service, um, let's just take one of them as an example, uh, so let's look at the um.
[CUSTOMER][NEUTRAL] But
[AGENT][NEUTRAL] I'm just using this as an example. So let's look at the [PII] uh hospital bill for $58,948.
[AGENT][NEUTRAL] Now, there should be an uh when you, when you went to the hospital, normally you would turn in your major medical card. They would, they would ask for it. Um, and so what will happen is, is that they will send the bill originally to AdMed to be processed and you in turn will receive an explanation of benefits showing how they processed that claim. Now, as your secondary insurance,
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] That is what we're looking for is that explanation of benefits that shows the deductible.
[AGENT][NEUTRAL] Co-payment or co-insurance from AvMed that we are supposed to be paying. Um, now, the other thing that we are looking for is the diagnosis code and you won't get that from the facility. You'll get that from your doctor who, uh, um, you know, who went to the, you, you went to the, to the hospital for a reason.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, and what they will do is they will, it's called a diagnosis code or basically, the, the reason that you went, uh, was it for a backache, backache, a sprained arm, uh, you know, COVID or something like that. That is what the diagnosis is. And so that is what we're looking for for those two things. So, the very, very, very first thing that you would do is, um, you should have the explanation of benefits because they're required by law to send them to you. You should have the explanation of benefits for each.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, uh, data service that we're looking at, so there's the [PII], uh, facility bill, there's an urgent care bill.
[AGENT][NEUTRAL] Um, excuse, not an urgent care, but a surgery bill for $2,926. Um, there is also that diagnosis code or diagnosis that you had done, uh, for [PII] that was on [PII] for $428.80. Um, this is what we're looking for is the explanation of benefits from
[AGENT][NEUTRAL] Each of those uh um dates.
[AGENT][NEUTRAL] And then in addition to that, uh what we'd be looking for is the diagnosis code. Why, why did you uh go into the, the doctor for the surgery? I mean, what was it for? And, and they will have that, they usually will have, um, they will make notes as they are talking to you, um, and that is the, and they will put down the diagnosis and that is what we're looking for.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So once those are submitted to us, uh, that is what we're looking for and uh once that's submitted to us we finish processing the claim, but usually the very very first place that you would start would be to get those uh explanation of benefits from AMed.
[CUSTOMER][NEUTRAL] Oh OK.
[AGENT][NEUTRAL] So we, we need that first, uh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Cause, cause it says uh mm.
[CUSTOMER][NEUTRAL] I don't know why it says uh JP Farley Corporation, um, as the insurance provider and
[CUSTOMER][NEUTRAL] At the same time, the card says I, so I'm confused, little confused in that sense, uh, it's my my bad it's not, it's signal.
[CUSTOMER][NEUTRAL] That's uh the medical plan.
[AGENT][NEUTRAL] It
[AGENT][NEUTRAL] Is it Cigna? OK, OK. Well, that's um
[CUSTOMER][NEUTRAL] Yes, sorry.
[AGENT][NEUTRAL] No, no, that's fine. Uh, whoever your major medical is, whatever, whatever that is, um, uh, and, and as far as the, um, uh, you know, there's some things that are on here that the JP Farley Corporation, we can't, we can't process that anyway because it's, uh, they.
[AGENT][NEUTRAL] Prescription drug, but um, yeah, so sometimes what is listed on, on your um on your documentation, we just had, you know, sometimes it will be the billing provider rather than the provider itself. So it, it can be kind of confusing when that happens, but
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I would look at the, uh, I would look at the data service and the build amount. Now those are always the same. The data service and the bill amounts um are always going to be the same. So the, so on [PII], you know the bill amount is $428.80. So that will be on your explanation of benefits.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] And then you'll see the, the, the deductible co-payment or co-insurance and that's what your, your, um, policy with us, uh, takes care of. Now for this outpatient services, uh, what we will do is we will pick up that deductible co-payment or co-insurance up to $1000 per calendar year. So once we, we get those uh documents from you, then we can go ahead and and finish processing it and um.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, that's, then we can go ahead and finish this.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I, I remember at admission, uh, the day of the surgery, uh, I had to deposit, uh, I have to give them, uh, $3000 as an upfront cost, and then I would reach a payment agreement for, you know, time to time. It was a lot of money. Um, so they gave me the admission, um, so I don't know if that's, that's uh valid, the admission, uh, uh, they gave me I don't know some sort of paper.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Uh, explaining basically what the doctor did during uh the surgery and what was, uh, you know, uh, what was supposed, what, what I was supposed to do on the following weeks, uh, well, you know, physical therapy and stuff like that. So they, they give me a lot of people just, uh,
[CUSTOMER][NEUTRAL] Uh, I got a search for it and upload it to the page, um,
[CUSTOMER][NEUTRAL] Uh, can I reach back to you if I don't know until what time you guys are available today?
[AGENT][NEUTRAL] Yes, we're, we're uh, we are open until [PII], uh, Eastern Standard Time, excuse me, Eastern Stan well, excuse me, Central Standard Central Standard Time, yeah, so, um, yes, so, uh, if you wanted to go ahead and, and contact us, you know, and we can look at the paperwork, but, um, if not, uh, then we can certainly do it tomorrow, but, um, yes, that's, that is what we're looking for or are those documents and we can see what it is, and any, and any one of our agents would be able to assist you.
[CUSTOMER][NEUTRAL] OK. It's, it's [PII]. OK.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Oh, OK, OK. OK, perfect. OK, I will do that. Thank you very much for the explanation. It really helped me a lot and I'll proceed to, to upload those, those docs right now.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK, well, thank you very much for contacting APL. Is there anything else at all that I can help with?
[CUSTOMER][POSITIVE] No, that was it. Thank you very much.
[AGENT][POSITIVE] OK, you have a very good evening