AccountId: 011433970860
ContactId: 0a71be93-110a-49a5-ac0a-405929da5c21
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1015450 ms
Total Talk Time (AGENT): 490020 ms
Total Talk Time (CUSTOMER): 226604 ms
Interruptions: 1
Overall Sentiment: AGENT=0.4, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/15/0a71be93-110a-49a5-ac0a-405929da5c21_20250115T21:16_UTC.wav
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[AGENT][NEUTRAL] Hi, thank you for calling ATL. This is [PII]. How can I help you today?
[CUSTOMER][NEUTRAL] Hi, my name is [PII]. How are you?
[AGENT][POSITIVE] I'm doing great. How are you, [PII]?
[CUSTOMER][NEUTRAL] Good, good. I have a question and I have a concern. OK, I, I had, I had a treatment.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] And uh and uh insurance cover X amount and the the the FPO did not cover anything and I would like to know what was the reason.
[AGENT][NEUTRAL] OK, I can look into that for you. Do you have your policy number handy at all, my friend?
[CUSTOMER][NEUTRAL] Policy number is IPO. Hold on.
[CUSTOMER][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] uh
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] You said that um
[CUSTOMER][NEUTRAL] In or out patient.
[AGENT][NEUTRAL] Either one of those numbers will get me where I have to go.
[CUSTOMER][NEUTRAL] OK. 02.
[CUSTOMER][NEUTRAL] 28
[CUSTOMER][NEUTRAL] 82
[CUSTOMER][NEUTRAL] 08
[CUSTOMER][NEUTRAL] ML 7
[AGENT][POSITIVE] Thank you. I appreciate it.
[AGENT][NEUTRAL] And
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Would you be able to verify for me, pretty please, your last name and your date of birth?
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And I do just have a couple other pieces of information I have to verify with you, um, your mailing address if that's OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Wonderful. And then just two other things one's that phone number on file and then the email.
[CUSTOMER][NEUTRAL] Uh, phone number?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Perfect.
[AGENT][NEUTRAL] And then that email for me please?
[CUSTOMER][NEUTRAL] Uh, no, I don't have one.
[AGENT][NEUTRAL] All right. And.
[AGENT][NEUTRAL] Let me see. I'm looking at that last claim that processed. Um, do you know what it was for if it or what date you were seeing?
[CUSTOMER][NEUTRAL] Uh, is it, uh, uh, is a gastro.
[AGENT][NEUTRAL] I have a Kendal endoscopy.
[CUSTOMER][NEUTRAL] Different like gastro.
[AGENT][NEUTRAL] Castro.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] All right. And I'm just looking at that claim information right here.
[AGENT][NEUTRAL] All right. So the last one I'm looking at.
[AGENT][NEUTRAL] That one for Kendall and endoscopy was from [PII], and when I look into it, it says that the above claim appears to be a duplicate of a previously submitted expense, and that benefit payment has been made to the insured.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] So I went back and I do see here right before that we received a claim from yourself and it had some stuff from vital imaging, from integrated cellular, um, and then a Doctor [PII] and [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Um, and so I do have that claim on file, um, that has a lot of information. Uh, it looks like that claim did have the benefits payable of 2573 for one of the charges from vital imaging, but then we did have some denial codes on that claim. Um, the first one is just that consultation fee and it states that office visits are not covered by the policy, um.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Uh huh.
[AGENT][NEUTRAL] And then the rest of them say that the claim is a duplicate of a previously submitted. So it looks like when I go back to that one, that vital imaging did their own claim before you had submitted that information, um.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Oh no, it looks like.
[CUSTOMER][NEUTRAL] But I, I believe the, the, the, I, I believe the virus was totally different from, from the, for, for the gonastropy.
[CUSTOMER][NEUTRAL] But it is the same
[AGENT][NEUTRAL] So it is different, the vital imaging and the endoscopy. So I just keep going back through them. It looks like the claims were submitted by the.
[AGENT][NEUTRAL] By you the first time originally um back in
[CUSTOMER][NEUTRAL] Yes, because I, I, I was, I was claiming the 25 and I was getting the, the vital that was claiming. I was not claiming about the the the the gastro.
[AGENT][NEUTRAL] OK, so that first claim that came in at the start of December, um, it had the vital imaging on it and that was already paid out in that claim, um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And so that was a benefit we gave you of $828.96. And so it looks like it.
[CUSTOMER][NEUTRAL] Yeah, with that I have that on my end.
[AGENT][NEUTRAL] OK. Um,
[CUSTOMER][NEUTRAL] So because it looks like you you only pay X amount instead of paying the whole thing.
[AGENT][NEUTRAL] So it looks like for vital imaging on that one, the charge was 2573, and that's what we paid um for the next vital imaging charge, um, the charge was 3927, and that's what we paid out um for Kendallnoscopy Center, uh, the charge was 76396, and that's what we paid out.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Um, it looks like you did have a couple other charges that were denied on there as well.
[CUSTOMER][NEUTRAL] Because
[CUSTOMER][NEUTRAL] Because I, I, I got, I, I, I got a bill from them which is 1,565, which that means I have to pay, well, minus minus the $700 you guys sent me, so I mean I have to I have to pay the balance.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] When when you submitted the claim, we submit the money to you instead so it doesn't go to your provider.
[CUSTOMER][NEUTRAL] No, no, I know.
[CUSTOMER][NEUTRAL] I have, I have the $700. I, I had, I have the check here in front of me, but the thing is the the gastro, they, they're saying I have to pay 55 $1,565 minus the $760 which the, the, the check you sent me was the 760 plus uh $96 with that means I have to pay $800 with sorry I had to pay $10801 with 4 cents.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So you guys did not, did not cover the, the, that amount?
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] I
[CUSTOMER][NEUTRAL] I don't know if I, if, if, if I explain myself or not, you know.
[AGENT][NEUTRAL] So, which, OK, so which facility did you say is send you the bill for the 1000, the imaging or the endoscopy center?
[AGENT][NEUTRAL] Cause they're all mixed in together, so.
[CUSTOMER][NEUTRAL] And got the gonostropine.
[AGENT][NEUTRAL] OK, so let me look at that one they're just all mixed in, so it's hard for me to like pull them apart and see which charges were for which, OK?
[CUSTOMER][NEUTRAL] Yes, yes.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] So on this claim 353-832-1.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] We have
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 3996.
[AGENT][NEUTRAL] So the only thing I'm seeing for the Kendal endoscopy is that
[AGENT][NEUTRAL] The charge of the 763.96.
[AGENT][NEUTRAL] Um, from what was sent into us from you.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, and so that is.
[CUSTOMER][NEUTRAL] Yes, I know I have this. I have this, I have it. I have the check here with me. I, I haven't, uh, cash it up, but the thing is the guy is charging me like $1000 and something with, with the check you sent me. I would have to pay like 108 out on my pocket. I have to pay 10801 something.
[CUSTOMER][NEGATIVE] So that means you, you, you guys did not cover anything like the whole thing?
[AGENT][NEUTRAL] So we're not, we don't guarantee to cover everything. We do apply charges to treatment and charges that fall in the purview of your like policy with us. So some things like prescriptions aren't covered, your consultation fees aren't covered, um, but like your treatment things might be covered or your diagnosis might be covered, um.
[AGENT][NEUTRAL] With that being said, all I'm seeing, like, as far as that, from all the stuff that was sent into us, um, for the Kendall endoscopy was the, that facility charge to the 76396 that was paid. And then I'm seeing the one that they sent to us, um.
[AGENT][NEUTRAL] That we denied telling them it was a duplicate of a previous submitted charge, but it was for like 3,576 um so it was for more than whatever they're billing you for, um.
[AGENT][NEUTRAL] But the, the
[AGENT][NEUTRAL] I'm
[AGENT][NEUTRAL] I don't know, so like that's as much as I can see what I can do if you want, is I can try to get um.
[AGENT][NEUTRAL] Somebody who processes claims on the line to see if they can go through it just because they might have more experience looking through these claims than I have because I don't process them myself, you know what I mean? and try to get somebody on there OK alright I'm sorry I couldn't help or I couldn't figure it out for you, [PII] but let me just put you on a quick hold and get you on the line with someone who examines those claims and see if they can help you through it, OK?
[CUSTOMER][POSITIVE] Yeah, that'll be, that'll be good. Yeah, of course.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you, 1 2nd.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][POSITIVE] This is easy.
[AGENT][NEUTRAL] Hi, this is [PII] with the care team and who is this again? I'm sorry.
[CUSTOMER][NEUTRAL] Um, this is [PII].
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] I'm sorry, I thought you said [PII] at first. I just want to make sure I got you right.
[CUSTOMER][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Um, Ms. [PII], I have an insured on the line. Um, his policy number is 02288208.
[AGENT][NEGATIVE] Um, his name's [PII]. I verified him and everything, and he's calling. He's, he's really upset. He doesn't understand why we're not covering, um, his bill, and he's got a charge from these guys. But like, I'm trying to look through his like claims and they're all just like a mess of resubmitted claims on top of each other. And so I'm just like trying to help him out to see if I can identify like what codes maybe weren't covered under the charge he's getting so I could explain it to him.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] But I, I just, maybe I'm not well versed enough. I, I think he just needs more assistance than I can offer him.
[CUSTOMER][NEUTRAL] OK. All right. Is this callback number the one on the system?
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Um, yes, it is. Um, the bottom claim, uh, the paid to him one for $800 it had a charge on it from Kendall Eonoscopy, and he said that they're billing him like $1000 but we only gave him $800. But I can see like all the stuff he submitted like is from different providers and
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] It, I don't know, like it's a whole mess, um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then that top claim, the most recent one, that one came from that, um, facility, and we denied it as a duplicate and you can see the charge was like 3500 something. So I was trying to look at those two claims to see if I could figure out what matched up and I couldn't if that in any way helps point you in the right direction of what he's gonna be asking for, um.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And those were
[AGENT][MIXED] I don't know, it's, I mean, it's really messy, so I'm really sorry, but I really appreciate you.
[CUSTOMER][NEUTRAL] Yeah, well it's almost time to go now I'm just, you can send them over.
[AGENT][NEUTRAL] OK, I'll introduce you when we join Miss [PII]. Is that OK?
[CUSTOMER][NEUTRAL] That's fine.
[AGENT][NEUTRAL] Thank you, sorry, I got a loud car one sec.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Perfect.
[AGENT][NEUTRAL] Hi [PII], are you still there with us?
[CUSTOMER][NEUTRAL] Yes, yes.
[AGENT][POSITIVE] Hey, thank you so much for your patience. Um, I do have Ms. [PII] on the line. She is one of our claims examiners, and she's gonna be able to hopefully provide you more insight and information than I was able to, um, but here she is for you, my friend.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] My pleasure.
[CUSTOMER][NEUTRAL] Hello [PII], um, I'm E in the claims department, and one moment, I'm pulling up your information.
[CUSTOMER][NEUTRAL] OK, yes, sir, was there a particular claim that you wanted to ask about that you needed to verify payment on?