AccountId: 011433970860
ContactId: 0755d6e2-deca-47f8-b3e0-0711473b9c8e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 800859 ms
Total Talk Time (AGENT): 344792 ms
Total Talk Time (CUSTOMER): 233694 ms
Interruptions: 1
Overall Sentiment: AGENT=0, CUSTOMER=-0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/17/0755d6e2-deca-47f8-b3e0-0711473b9c8e_20250317T18:29_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yes, I was calling just to uh check and make sure that they have all the paperwork that they have in the uh fax.
[AGENT][NEUTRAL] Um, yes, sir. I can assist you with that information. Um, first, could I get your name and a good callback number just in case we're disconnected?
[CUSTOMER][NEUTRAL] Yes, [PII].
[CUSTOMER][NEUTRAL] And the number is [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you, [PII]. Now, could I get your policy number, please?
[CUSTOMER][NEUTRAL] Oh, that I don't have with me because I'm at work.
[AGENT][NEUTRAL] OK, I can look it up by your social.
[CUSTOMER][NEUTRAL] OK, my social is [PII].
[CUSTOMER][NEUTRAL] 19
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you. Could you please verify your date of birth and your mailing address?
[CUSTOMER][NEUTRAL] [PII], my mailing address is [PII].
[AGENT][NEUTRAL] OK. Thank you. Now please verify your email address.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you. And what's the date of service and bill charges for the claim you're calling about?
[CUSTOMER][NEUTRAL] For
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII] and [PII].
[AGENT][NEUTRAL] OK. Yes, sir. I'm showing that we did receive that claim and
[AGENT][POSITIVE] It actually have already processed and paid out. It processed on.
[AGENT][NEUTRAL] Um, [PII], and it paid out for $300 even.
[CUSTOMER][NEUTRAL] For both claims?
[AGENT][NEUTRAL] Yes, sir.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] I wonder why so little when I paid over $1000.
[AGENT][NEUTRAL] Well, I'm showing, um, let's see. For some of the services, I'm showing that your primary insurance covered the charges in full.
[AGENT][NEUTRAL] And then for other services like the co-pay for the office visit, that's not covered under your policy.
[CUSTOMER][MIXED] OK, but I had to pay uh.
[CUSTOMER][NEGATIVE] $500 for the facility, 100 and something dollars for the doctor, and then at the other one where I did the X-ray and stuff, I had to pay $500 out of pocket for my copay.
[CUSTOMER][NEGATIVE] So I don't see what they're saying that my insurance covered it.
[AGENT][NEUTRAL] OK. Well, if your primary insurance um denied a charge, I'm showing that as well, then we don't deny it either as your um we don't cover it either as your secondary insurance. So I'm showing that um
[AGENT][NEUTRAL] Yeah, the diagnostic center.
[AGENT][NEUTRAL] One of the charges your primary insurance did not cover, so we denied it also. And then for those other charges, I'm showing that your primary insurance did cover those in full. So there was no portion for us to cover.
[CUSTOMER][NEUTRAL] OK, well what about the portion that I paid out of pocket?
[CUSTOMER][NEGATIVE] You should have it should on that on them two cases it should be 3 receipts for my out of pocket expense where one of them, the receipt is both of the receipts is $500 something dollars and then one receipt is $105 147 dollars or something like that.
[AGENT][NEUTRAL] OK, let me look at the receipts. One moment.
[AGENT][NEUTRAL] OK, and the documents are coming up. I'm waiting on my system.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Because I think the two receipts for [PII] came up to 600 and something dollars.
[CUSTOMER][NEUTRAL] I think that's when I went to the gastrologist.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] OK, I'm not showing any documentation for [PII]. I'm showing [PII].
[CUSTOMER][NEUTRAL] Yeah, that's what I'm talking about. It was [PII].
[AGENT][NEUTRAL] Yeah, and that was for the imaging facility. And yes, sir, that one paid out for $300. 1 line um paid out for $300 and the other line denied because your primary insurance, Aetna, paid that charge in full. That was for [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] And then there was other charges for [PII]. There was one more where your primary insurance denied it. And again, if they denied, then we denied also. So that's why [PII] only paid out for $300. And then I'm showing.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Alright, go ahead.
[AGENT][NEGATIVE] And then there's another one for a date of service, [PII], and I'm showing that this one denied because.
[AGENT][NEUTRAL] According to your primary insurance, um, Aetna, they covered the charge in full, all except for the co-pay for the office visit, which is not covered under um the policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] So that's why that denied because the co-pay um is not covered under your policy and then the other charges for the services, um your primary insurance covered that in in full.
[CUSTOMER][NEUTRAL] OK, what about the other receipt for the 100 and something dollars for the doctor, the $500 something dollars for the facility.
[AGENT][NEUTRAL] OK. Yeah, the only documentations we have are for [PII], I'm sorry, [PII] and [PII].
[CUSTOMER][NEUTRAL] I know [PII] is when I went to to call you, right?
[AGENT][NEUTRAL] [PII], let's see.
[AGENT][NEUTRAL] This is for the outpatient service for the Wellness Avenue Surgery Clinic.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, for the colonoscopy.
[AGENT][NEUTRAL] Yes, sir.
[CUSTOMER][NEUTRAL] OK, and I had to pay $500 for.
[AGENT][NEUTRAL] And
[CUSTOMER][NEGATIVE] The use of the building, I had to pay $100 something dollars for the doctor.
[CUSTOMER][NEGATIVE] And I don't get none of that back.
[AGENT][NEUTRAL] Well, I'm showing, I'm only showing the receipt, let's see. Yeah, we, we only have the receipt and the EOB for
[AGENT][NEUTRAL] For the doctor. We're not showing the receipt for the facility. So you can resubmit that information if you have it. If you have the receipt and the
[CUSTOMER][NEUTRAL] But that I sent, I sent both of them receipts together, so how can y'all have one and don't have the other.
[AGENT][NEUTRAL] Well, I'm looking at the documents. Let's see.
[CUSTOMER][POSITIVE] I like both of them streets.
[AGENT][NEUTRAL] I just.
[AGENT][NEUTRAL] One moment.
[AGENT][NEUTRAL] OK. Well, according to the primary EOB I see right here for date of service [PII] for the Wellness Avenue Surgery Center. According to the explanation of benefits, nothing went towards the copay, the co-insurance, or deductible. We're actually showing that your primary insurance covered this in full.
[CUSTOMER][NEGATIVE] They did not because I sent the receipt where I had to pay the $500.
[AGENT][NEUTRAL] Well, I apologize, sir. We don't go by the receipts. We go by the primary insurance because that's who we work with.
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEGATIVE] OK, so the receipts that I sent where I paid out of pocket, so I should have just kept them.
[CUSTOMER][NEUTRAL] Why did they have me to send?
[AGENT][NEGATIVE] Well, no
[AGENT][NEUTRAL] You needed to send a receipt because your diagnosis code is on there. Under your policy, we only cover services that are related to an illness or an injury. So we needed the receipt to verify your diagnosis code to make sure that it was related to an illness or an injury.
[AGENT][NEUTRAL] Which it was, so.
[CUSTOMER][NEUTRAL] Alright, so you're telling me that I paid $1100 something dollars out of pocket and my secondary insurance is only gonna replace $300 something dollars or $300.
[AGENT][NEUTRAL] Well, we're going by the documentation we received, sir. If you send us an explanation of benefits showing what uh the, the additional amount went towards the copay, the co-insurance or deductible, and if you have the benefits available, we'll pay it out, but we can only go by what we see. And according to the documentation, we have only 300 is due.
[CUSTOMER][NEGATIVE] Because the documentation that y'all have, y'all have all the receipts where I paid out of pocket and you're telling me that y'all don't have the documentation though.
[AGENT][NEUTRAL] According to the primary explanation of benefits. Mhm.
[CUSTOMER][NEUTRAL] All, all, all of that, in other words.
[CUSTOMER][NEUTRAL] In other words, all the uh.
[CUSTOMER][NEUTRAL] Receipts
[CUSTOMER][NEUTRAL] That you got where I paid $500 something dollars on 2 and $100 something dollars on one all that I paid out of my pocket.
[AGENT][NEUTRAL] Right, but we go by, we go by your um primary insurance. Do you know, do you understand what this policy covers, sir?
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] No, I don't. I really don't, but I got one question for you.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] When I go to one of my doctors.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Can I hand them your own card?
[AGENT][NEUTRAL] Yes, sir. Please do so they can give us a call to verify your benefits.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEGATIVE] Because most doctors you go to now they want the copay up front, so by me handing them your card that still ain't gonna help me.
[AGENT][NEUTRAL] Well, the co-pay is for doctor's visits. That's, that's not covered under this policy, but treatment provided in the office is covered.
[AGENT][NEUTRAL] So a portion of the office visit is covered. If, if your primary insurance doesn't cover it. According to the documentation that we've received, your primary insurance um covered some charges and then some charges in the office, your primary insurance denied. So again, if your primary insurance cover it in full, there's nothing left for us to pay and if they deny it, then we deny it also as your secondary insurance.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] So basically I thought I was having a secondary insurance to cover what my primary insurance deny or don't cover, but you telling me that if the primary insurance denied y'all denies it too.
[AGENT][NEUTRAL] Yeah, we did not also have the primary insurance deny it, but if it goes towards the copay.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][POSITIVE] Alright, thank you.
[CUSTOMER][POSITIVE] Thank you have a blessed day.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Is there anything else I can assist you with?
[CUSTOMER][NEUTRAL] No, that's it.
[AGENT][POSITIVE] Yeah, thank you for calling APL. You have a blessed day as well.