AccountId: 011433970860
ContactId: 0276b58c-e9a4-47a3-98c6-d72ae74e9982
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 725659 ms
Total Talk Time (AGENT): 458117 ms
Total Talk Time (CUSTOMER): 248478 ms
Interruptions: 5
Overall Sentiment: AGENT=0.3, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/28/0276b58c-e9a4-47a3-98c6-d72ae74e9982_20250228T20:08_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APA. You're speaking with [PII]. How may I help you today?
[CUSTOMER][NEUTRAL] Yes, [PII], uh, my name is [PII], and I have a claim number.
[AGENT][NEUTRAL] OK, Mr. [PII]. Give me your phone number just in case we get disconnected.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] All right. And Mr. [PII], let me have the policy number.
[CUSTOMER][NEUTRAL] OK 025.
[CUSTOMER][NEUTRAL] 355.
[CUSTOMER][NEUTRAL] 83.
[AGENT][NEUTRAL] Right. And Mister, your name, Mr. [PII], is that correct?
[CUSTOMER][NEUTRAL] [PII], yeah.
[AGENT][NEUTRAL] OK, Mr. [PII], verify your date of birth and your mailing address for verification.
[CUSTOMER][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Uh, [PII] in [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] All right. What about your email address on file?
[CUSTOMER][NEUTRAL] Uh, it should be [PII].
[CUSTOMER][NEUTRAL] Uh, [PII].
[AGENT][NEUTRAL] All right, thank you for that information. Now, is the claim number that you're calling it's gonna be on you or someone else?
[CUSTOMER][NEUTRAL] Uh yes ma'am.
[CUSTOMER][NEUTRAL] It's on my wife.
[AGENT][NEUTRAL] OK, and that's gonna be part 2. And her name is?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, I got it. What's that claim number that you're calling in reference to?
[CUSTOMER][NEUTRAL] Well, it's uh 356-691-6.
[AGENT][POSITIVE] OK, I do see it. How can I help you with today?
[CUSTOMER][NEUTRAL] Well, uh, I was expecting a much larger check because I had sent in 7 chemo treatments. I've been paid on 3, let me find, and I haven't cashed that check yet. Let me find, get in here.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, how much that check was?
[CUSTOMER][NEUTRAL] So there's 3 chemo treatments they picked up.
[AGENT][NEUTRAL] But what, what was the amount of the check that they gave you? That's what I'm asking.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] $812.11 is the one I just received.
[AGENT][NEUTRAL] OK. So I do see that and I do see they pay chemo for data service 11/21. They pay chemo for 11:27, 125, 1212, 1218, 1227, and 11:14. So that's those, what date did you think they missed?
[CUSTOMER][NEUTRAL] Well,
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Chemo radiation the check I got uh.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] September I got a $5,255.94.
[CUSTOMER][NEUTRAL] Check that was dated [PII] and they paid me $1,564 and 18783 and then the next one they paid $187 and $1564 and then they paid me $187 and 1564. Now I'm just getting these little payments and I was expecting.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, now you do, you know, you do know that your chemo is based on what the primary applies towards the uh.
[AGENT][NEUTRAL] You know, with the primary pay. So on those dates of service we go by what you say if the bill is and I, I, I, I don't have the claim pulled up, but say if the chemo for that data service, say it was $5000 that's what the provider charged you. But say I'm just giving a name of a company, say Blue Blue Cross Blue Shield.
[AGENT][NEUTRAL] You only pay $150. The most we're going to pay is $150 for that day, and that's what, that's why that P1E006 is on there letting you know we went by actual charges. We don't go by what the provider charged. We go by extra charges paid by the primary insurance carrier.
[AGENT][NEUTRAL] For each day that she was given the chemo.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Well,
[CUSTOMER][NEUTRAL] Uh, but I don't know if that matches because now I wasn't paying because I had met my deductible, but let me.
[AGENT][NEUTRAL] No, but whether you paid or not, when you, when we get a claim, and this is any insurance company, and it goes by after charges, if the provider charged $8000 and just say you got Blue Cross Blue Shield and they only pay $150 towards that $8000 that that provider charged, the most we're going to pay is the $150 not the $8000 benefit.
[AGENT][NEUTRAL] For that data service only what your primary insurance carrier pay on your behalf. Not what you pay, but what they pay for that particular data service.
[CUSTOMER][NEUTRAL] Well, see, and I'm showing OK on one of these uh.
[CUSTOMER][NEUTRAL] Because I sent all these pages uh.
[AGENT][POSITIVE] Uh-huh, I'm gonna bring it up and if I can go over it with you.
[CUSTOMER][NEUTRAL] It it shows paid 1805-69 um.
[AGENT][NEUTRAL] The plan, but what was allowed. You gotta look at what was allowed. OK, let me, let me, OK, let me uh pull it up. Let me see what this is number 360. So let me get 360.
[CUSTOMER][NEUTRAL] That's it.
[CUSTOMER][NEUTRAL] Pro
[CUSTOMER][NEUTRAL] That's for [PII]. They paid 1805-69.
[AGENT][NEUTRAL] Uh-huh, I'm, I'm gonna look for it.
[AGENT][NEUTRAL] Um, I'm gonna look it up.
[AGENT][NEUTRAL] And see what we got here.
[CUSTOMER][NEUTRAL] Now there could be another check coming. I don't know.
[AGENT][NEUTRAL] And it didn't show that another check is coming. It does not show that another check is coming. The last claim was that claim number that you gave me, and that's what we processed it on. So let me go down here and find date of service [PII] for you and go over that explanation of benefit with you.
[CUSTOMER][NEUTRAL] But uh
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, and then [PII] and my plan paid $1,806.08.
[AGENT][NEUTRAL] OK, I'm looking for it but yeah.
[AGENT][NEUTRAL] OK, it's just your name.
[CUSTOMER][NEUTRAL] In 1790 179096.
[AGENT][NEUTRAL] OK, here we go. This date of service is [PII], and let's see what you got here. I'm looking for the chemocharge plan. OK, let's layout and put to the next one.
[CUSTOMER][NEUTRAL] 1843.
[AGENT][NEUTRAL] Mm 7. OK, here it is. OK, here we go. [PII], the provider and let me go to the claim, make sure I got the right one.
[CUSTOMER][NEUTRAL] So I show infusion.
[AGENT][NEUTRAL] Mhm. And this is, uh, uh, right here under the medication deductible and it got 1114. Providers charge was $161.25. The plan covered up to $116.10 and that's what we paid for data service, [PII]. If you see provider charge, that's with the provider charge.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] But what about infusion, infusion and therapy 1163.
[AGENT][NEUTRAL] No, that's not, that's not covered. This is the chemo.
[AGENT][NEUTRAL] You got chemo, radiation, chemotherapy.
[AGENT][NEUTRAL] But now, if you don't agree with the payment that was paid, you can always do an appeal letter saying what you're appealing and what you thought should have been paid.
[CUSTOMER][NEGATIVE] Well, I don't understand why they paid me.
[CUSTOMER][NEUTRAL] More
[AGENT][NEGATIVE] Because on that code 96413, that is not a cover benefit on our policy. It only takes actual chemo charges. This is an administrative charge that that infusion therapy, 96413, that's administrative charge and it's not covered on your policy under the chemo radiation chemotherapy benefit. And that's why that was not payable.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Yeah, but I have to look it back and see.
[CUSTOMER][NEUTRAL] Let's see how far back.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] But the the check that y'all paid before.
[AGENT][NEUTRAL] And when, what's that claim number?
[CUSTOMER][NEUTRAL] Um, well, I'm gonna have to go back and look. Let me, uh, because I don't have all my, I just have what I just sent y'all, I think.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, yeah, the last check we paid was 5 before that one was $5,255.94 and we paid uh chemo and it did uh the, on that one of them, the charge was $1,564.16. That's what the provider paid.
[AGENT][NEUTRAL] So we have to pay what the provider pay and when you see that P1E006, that means we pay actual charges, not what the bill amount was but actually what the.
[AGENT][NEUTRAL] Primary insurance carrier pay and that's how you got that $5000 something dollars because we pay that and then on data service 1010, the amount that was charged was $187.81. That's what we paid for 912 of 2024 $187.87.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Then another charge 100, we paid that $1,564.16. 1024, it was $187.81 1024 $1,564.19. So yes, we did use extra charges for that one also.
[CUSTOMER][NEUTRAL] I guess I'll need to go back and look and see.
[CUSTOMER][NEUTRAL] Those charges and and and see if I can.
[CUSTOMER][NEUTRAL] Figure out
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] You know, see what I can see about figuring out.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Because you're talking about what no it wouldn't be what we paid. I just have to look at I'll look at the codes.
[AGENT][NEUTRAL] No, it'd be, it'll be when you see, if you see, if you see data service uh [PII], if you got that up, if you see provider charge, they charge $161.25. Your plan coverage, that means your company, whoever you with blue.
[AGENT][NEGATIVE] Blue Shield, and whoever you're with, they only pay 1 1610. That's what you got to look at. That's what we pay. Anything else on there like lab is not covered, any of those infusion codes that start with 96, they are not, they're not covered. They're not covered. Uh-huh.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Those aren't covered, OK.
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] See, I understand what you're saying that's that's what I need to go back and look and and and compare what y'all are paying and then what was charged and and and then uh.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, OK, and then if you have any questions once you compare, you can always call back and let us verify what was paid and why it was paid like that. Yes, sir.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, because I, I have all that paperwork so I just have to dig it out.
[AGENT][NEUTRAL] Oh OK.
[AGENT][NEUTRAL] OK, and just review it and if you have a question about something that you thought should have been paying more, you can just give our office a call back and we'll review that claim with you.
[CUSTOMER][NEUTRAL] What are you?
[CUSTOMER][POSITIVE] You, you've been you've, you've given me a good place to go back and look, so.
[AGENT][NEUTRAL] OK, all right.
[CUSTOMER][POSITIVE] Alright well I appreciate it, thank you, [PII].
[AGENT][NEUTRAL] All right. Anything else and nothing else I can help you with today, Ms. [PII]?
[CUSTOMER][NEUTRAL] No, ma'am.
[AGENT][POSITIVE] All right. Well, you have a wonderful weekend and thank you for calling American Public Life.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][POSITIVE] OK, thank you, ma'am. Bye bye.
[AGENT][POSITIVE] You're welcome. Bye-bye.