AccountId: 011433970860
ContactId: 0b5a9dbd-eebe-470f-a88e-afca32181e9c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1002840 ms
Total Talk Time (AGENT): 260192 ms
Total Talk Time (CUSTOMER): 386007 ms
Interruptions: 2
Overall Sentiment: AGENT=0.6, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/08/0b5a9dbd-eebe-470f-a88e-afca32181e9c_20250408T15:31_UTC.wav
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[AGENT][NEUTRAL] Good morning. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEGATIVE] Uh, yes, I'm calling about um uh some claims I made. I had actually called several weeks ago and they uh had me talk to a claims person and they told me exactly what to do and it's still not being processed. They're still saying I haven't seen in what I needed so I was just calling referencing that.
[CUSTOMER][NEUTRAL] Uh, they said I still need, they say that, uh, I sent in, they told me send in the explanation of benefits that Blue Cross sent you and it does have on there what the deductible was and, and what was paid, but they're saying it doesn't and they need more um they need more, you know, more detailed explanation so it's like how do I get that? Do I go to Blue Cross, um.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] And also it said they had told me uh that, that there was some problem because he was going through the, the, you know, doctor or hospital and so they told me to, they sent me a form and said we want you to submit this on your own. So now I've got a duplicate duplicate claim on it as well. So anyway, I'm just confused about what I need to do next.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, let's see, let's see what we need to do, and I'm sorry for that. Um, let me have your name and a callback number just in case we get disconnected.
[CUSTOMER][NEUTRAL] OK. OK, my name is [PII].
[CUSTOMER][NEUTRAL] And my number is [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. And may I have the policy number, Miss?
[CUSTOMER][NEUTRAL] Uh, let's see, um, policy number is 00769779.
[AGENT][NEUTRAL] It was 1779 or 1779?
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] 00769779
[AGENT][NEUTRAL] OK, Miss [PII], for security, may I have your date of birth, mailing address and email address on file for verification.
[CUSTOMER][NEUTRAL] Uh, my, uh, birth date is [PII]. My mailing address is [PII], and, and my, uh my email address is [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] All right, thank you.
[AGENT][NEUTRAL] OK, let's see. Let me go to the claims.
[AGENT][NEUTRAL] OK let me pull the most recent.
[AGENT][NEUTRAL] Explanation of benefits. OK, one moment.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Mhm OK.
[AGENT][NEUTRAL] OK. So yes, the, the explanation of benefits did not list the amount applied towards the deductible co-payment and co-insurance. Have you tried to contact um your primary insurance to get a fully, um,
[AGENT][NEUTRAL] Like itemized. Have you uh tried to contact your primary um insurance to get a detailed explanation of benefits?
[CUSTOMER][NEUTRAL] Get a what?
[CUSTOMER][NEGATIVE] No, they didn't tell me to do that. They told me they told me to send what they told me to send what I got in the mail.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So, so I need to contact Blue Cross. Blue Cross is my primary.
[AGENT][NEUTRAL] Oh OK.
[AGENT][NEUTRAL] Yes, um, you need to contact Blue Cross and let them know that you're trying to get the explanation of benefits for the state of service, and it needs to have the amounts applied towards the deductible co-payment and co-insurance that you're trying to submit a claim.
[CUSTOMER][NEUTRAL] And tell him
[CUSTOMER][NEUTRAL] OK, I think that
[CUSTOMER][NEGATIVE] I think what the issue is, is that it's very general on what they send me. It's just like the date and the service. It was like, it was like for a biopsy and so they basically say, here's the, here's the total amount we, we applied for the, you know, that we are charging for the biopsy and here's what we paid and so forth. And so apparently that's not, that's the issue, that's not enough.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Yeah, the issue is that it's not showing um if we need to pay this towards the deductible co-payment and co-insurance because it's not detailed enough to let us know where we need to apply this to.
[AGENT][NEUTRAL] So we just need the, yeah, the explanation of benefits that shows that it was applied either towards the deductible, co-payment, and co-insurance. So it cannot just say patient's responsibility. It needs to be applied towards the deductible co-payment or co-insurance.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, well, it does have that it does let me see, let me look at that. I have that.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, yeah, the statement of that just a minute. Let me look at that and see. I've got that right here. OK, OK, yeah, on the.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] On the statement it says um.
[CUSTOMER][NEUTRAL] OK, um,
[CUSTOMER][NEUTRAL] It's got, you know, what the pan like it has a section where it says what the pants, what the plan paid and then it's got deductible.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then it's got what the coinsurance is it has it on there but.
[CUSTOMER][NEUTRAL] You know, like I said, it's like one thing like biopsy and it's for the whole total thing, it's not working out, so I mean that's what I don't understand is, is on the, on what I'm sending all it does have uh under your responsibility it says deductible co-pay, co-insurance.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And there's an amount under that one of those?
[CUSTOMER][NEUTRAL] Yeah, it's them out.
[AGENT][NEUTRAL] OK, so the amount is under which one? Co-payment, co-insurance or deductible?
[CUSTOMER][NEUTRAL] Uh, there's an amount under deductible and there's amount under copay and co-insurance.
[AGENT][NEUTRAL] Deductible.
[AGENT][NEUTRAL] OK, and this is for date of service, [PII] and [PII].
[CUSTOMER][NEUTRAL] Right, let me see. Let me look, let me pull that. I've got that all. I've got make copies of what I sent y'all just a minute.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] Uh, I'm just looking at 11 in general. Let me look at that and see.
[AGENT][POSITIVE] OK, sure, no problem. Mhm.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK, let's see.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] part let's see, OK.
[CUSTOMER][NEUTRAL] Oh,
[CUSTOMER][NEUTRAL] OK, so what I have for 101, which was a PET scan.
[CUSTOMER][NEUTRAL] As it says on here it says hospital facility visit on there.
[CUSTOMER][NEUTRAL] And then it's got um under your responsibility we we had met our deductible so that says 0 and then it says copay coinsurance 38787.
[AGENT][NEUTRAL] On their co-pay and car insurance, that's the amount?
[CUSTOMER][NEUTRAL] Mhm, that's the that's just the amount.
[CUSTOMER][NEUTRAL] And I sent a copy of that.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] With that date highlighted, so that's the one for uh the [PII] which was a PET scan.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, um.
[CUSTOMER][NEUTRAL] OK, and then the [PII].
[AGENT][NEUTRAL] Mhm. You're her.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, on the [PII] there's like.
[CUSTOMER][NEUTRAL] To there.
[CUSTOMER][NEUTRAL] Uh, well, there's a, let's see.
[CUSTOMER][NEUTRAL] Although I've got, I think 2 pages of that because there's multiple.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Things listed on there.
[CUSTOMER][NEUTRAL] But here's the one for the actual uh.
[CUSTOMER][NEUTRAL] Actual um hospital visit where they did the biopsy and it's showing zero deductible because we've been our deductible and it's showing copay co-insurance is 37189.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then of course it's got, you know, other things for like an ultrasound and lab services and so forth that go along with that but the actual hospital facilities when they did the, the biopsy is on one of those, one of those um medical claim details that I sent in for explanation of benefits.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so
[CUSTOMER][NEGATIVE] That's why I'm not understanding why they're saying it's not on there.
[AGENT][NEUTRAL] OK, let me go ahead and get the claim support team on the line with us, OK?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And I'm just gonna go ahead and explain to them what you have told me, OK? One moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][POSITIVE] Good morning. Thanks for calling APO. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hi, [PII]. How are you? This is [PII].
[CUSTOMER][NEUTRAL] So he so how are you?
[AGENT][NEUTRAL] I'm good, I'm good, thank you. Um, I have a member on the line with the cancer policy and she's coming about her claim that she said that she's been going um on with this like about a week, um, that she's been getting EOB saying that she needs additional information, but she believes she sent the last information which is the explanation of benefits that were asked for, um, but, um.
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] She was pointing out.
[CUSTOMER][NEUTRAL] So what's the policy number maybe to pull it up while you're talking.
[AGENT][NEUTRAL] OK. 769-779.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] And let me know when you have it pulled up so I can.
[CUSTOMER][NEUTRAL] Uh.
[AGENT][NEUTRAL] Probably tell you what she's telling me and maybe you can just let her know what's going on.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] And it's the most recent claim.
[CUSTOMER][NEUTRAL] Yeah, OK.
[AGENT][NEUTRAL] And what she said is towards the bottom of the, you know, the paperwork she sent the 16 pages that she sent, she's talking about the ones listed on page 1415, and 16 under the co-insurance, or co-payment.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] I'm not sure if that's exactly what we're looking for, but that's what she's pointing out, so I'm not sure if she just needs something else.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Or, how can we help her?
[CUSTOMER][NEUTRAL] And more details.
[AGENT][NEGATIVE] She's a little bit frustrated because she don't know what else to say.
[CUSTOMER][NEUTRAL] I put a surgery in.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] I think it's 2.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] You can send her over. I'm gonna have to get with the examiner to see cause I don't see any of this information on this page that she got going on, so you can send her on over.
[AGENT][NEUTRAL] In January.
[AGENT][NEUTRAL] OK, here she come. I fully verify her the callback number is the same one in the system, OK?
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] OK, all right.
[AGENT][POSITIVE] Thank you for holding and being patient for Ms. [PII]. I got Ms [PII] on the line. She's in the claim support team, OK?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Have a good day.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] Good morning. Thank you for calling APO. This is [PII]. How are you?
[CUSTOMER][NEUTRAL] Bye bye.
[CUSTOMER][NEUTRAL] OK, good. Give me one second, I'm reviewing your claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right, Ms. [PII], I, I'm looking at your claim, but I need to ask.