AccountId: 011433970860
ContactId: 11bdfe9d-744d-49f1-aff1-0b269ae881d0
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1391599 ms
Total Talk Time (AGENT): 514161 ms
Total Talk Time (CUSTOMER): 510648 ms
Interruptions: 0
Overall Sentiment: AGENT=-0.2, CUSTOMER=-0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/18/11bdfe9d-744d-49f1-aff1-0b269ae881d0_20250618T16:38_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII]. Uh, I filed a couple of claims, actually forgot about it. I just, uh, sent out, um, like a few months ago. Now, I gave you all the forms. I literally went back to the hospital and gave you all the forms that I that I paid everything.
[AGENT][NEUTRAL] I.
[CUSTOMER][NEUTRAL] And I feel like, I don't know what you want from me else. Everything is like, you have it there. Can you please check what's going on?
[AGENT][NEUTRAL] OK. Do you have your policy number?
[CUSTOMER][NEUTRAL] Uh yes, so let me see it's the same number in both. Uh yeah. So it's 02003442.
[AGENT][NEUTRAL] OK. And then what was your first and last name and date of birth?
[CUSTOMER][NEUTRAL] My end is [PII]. Call me [PII]. One is for me and one is for my son at the end.
[CUSTOMER][NEUTRAL] From the claim.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And then can you verify your address for me and your email address?
[CUSTOMER][NEUTRAL] Yes. Sure, it's [PII].
[CUSTOMER][NEUTRAL] In [PII] and the email [PII].
[AGENT][NEUTRAL] OK, thank you. And then do you have a good callback number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yes, sure, it's [PII].
[AGENT][NEUTRAL] OK. Uh, let's check on, you said there was a claim for yourself and then one for your son?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And do you know when you filed that?
[CUSTOMER][NEUTRAL] Mm, um, I mean, I have the letters here.
[CUSTOMER][NEUTRAL] There's no place that I've seen it on the other side.
[CUSTOMER][NEUTRAL] Uh, yeah, there's a check date, [PII] for both. I don't know what check date means.
[CUSTOMER][NEUTRAL] I mean they could you check that site, I don't know.
[AGENT][NEUTRAL] Um, it looks like the, the last thing we received from you, let's see, this was from
[CUSTOMER][NEGATIVE] I, I tried to file it again with other forms, so I filed it first and then it was written or I talked to you. I don't remember, and you told me that I'm missing something else. I got that thing and I just refiled it again because it was, I didn't have a fax. They told me I should fax it. I just filed everything all over again with the document that we're missing in the previous time, so I don't know which one is that one. And uh then they declined it and I, I'm not sure why.
[AGENT][NEUTRAL] OK, so
[CUSTOMER][NEUTRAL] Or declined or wanted something else. I don't know what else can I get except everything I gave you.
[AGENT][NEUTRAL] OK, so you just faxed it, is that right?
[CUSTOMER][NEUTRAL] What?
[AGENT][NEUTRAL] You just faxed over the information, is that correct?
[CUSTOMER][POSITIVE] Yeah, I gave you all the information that you asked so yeah.
[AGENT][NEUTRAL] Oh, that's why I'm asking. Did you fax it today or when did you fax it?
[CUSTOMER][NEUTRAL] No, no, no, like a few months ago, a few months ago.
[AGENT][NEUTRAL] OK. Um,
[AGENT][NEUTRAL] The last thing I have on file for you is for we received back in March, it was for [PII].
[CUSTOMER][NEUTRAL] Uh, it may make sense, yeah.
[AGENT][NEUTRAL] Um, and that, that's the last thing we received. I looks like we were asking for, let me see.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, your explanation of benefits from your primary insurance?
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] That that's what I was checking. Do you know what date you sent that?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Are you there?
[CUSTOMER][NEUTRAL] Yeah, yeah, I hear you. Mhm.
[AGENT][NEUTRAL] Do you know what date you sent the fax?
[CUSTOMER][NEUTRAL] Ah, no, it makes sense that it was some day in March.
[CUSTOMER][NEUTRAL] I thought you're saying not asking.
[AGENT][NEUTRAL] OK, um, because I don't, I don't show anything additional received. We haven't received anything since the last claim submission. We haven't received any additional information. Let me check for your son. Um, what was your son's name?
[CUSTOMER][NEUTRAL] No, no, I, I maybe I, maybe I misexplained myself. I, the second time I submitted the claim, it was with the extra document.
[CUSTOMER][NEGATIVE] I submitted the same claims twice. Once they told me I'm missing some documents, so I submitted all over again as a new claim with the document that I was missing. At least what I found, what I thought I, you need. I don't know anymore, honestly, I gave you everything I had.
[CUSTOMER][NEGATIVE] I don't know what else can I, I mean, I paid it, I don't know why I'm not getting reimbursed for that.
[AGENT][NEUTRAL] OK, that's, that's what I'm, so we received back in [PII], and are you the patient, [PII]?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Is that correct?
[CUSTOMER][NEUTRAL] I'm the patient for one of the things, yeah, I'm my me and my son is for the other thing.
[AGENT][NEUTRAL] OK, so we received, um, it looks like we received a
[AGENT][NEUTRAL] Emergency, uh, looks like Olata River.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] And that the hospital gave me everything, all the documents the hospital gave me for me, the Ventura gave me everything.
[AGENT][NEUTRAL] That's the one
[AGENT][NEUTRAL] OK. So what?
[CUSTOMER][POSITIVE] With all the details.
[AGENT][NEUTRAL] What we were requesting is the primary explanation of benefits, which would be from
[AGENT][NEUTRAL] Um, looks like you have [PII], that's your primary insurance.
[CUSTOMER][NEGATIVE] Yeah, but, yeah, but, but [PII] told me that they don't have it. They're not keeping it.
[CUSTOMER][NEUTRAL] A few years before, the hospital is keeping it, and when I talked to you, you told me if you can get it from the hospital with all the explanation, that can work as well.
[CUSTOMER][NEGATIVE] Florida Blue Cross tell me that they, they're not keeping it.
[CUSTOMER][NEUTRAL] Tears backwards.
[AGENT][NEUTRAL] Well, they
[AGENT][NEGATIVE] They they should have your explanation of benefits on file because they have to keep that for like 7 years.
[CUSTOMER][NEUTRAL] Yeah, yeah, but you know, it's benefit, that's uh, the regular one, but you told me that I need, we, no, no, that I can send you. I don't even need them for that. But you told me that I need to send it like for the moment, like with all the things to say that to see how they applied it. So I told you they're not keeping it, so they told me that I can do it through the hospital. That's why I gave you. If you go and look on the documents from the hospital, everything is written from the documents in the hospital. That's what I submitted the second time.
[CUSTOMER][NEUTRAL] Everything, all the explanation, all the benefits, what they paid, everything is written from the hospital. They have all the explanations.
[AGENT][NEUTRAL] It
[AGENT][NEUTRAL] Right, I understand, but we have to have the information from Florida Blue. That's what, do you have access to their portal that you could print it off for us and send it?
[CUSTOMER][NEUTRAL] I can send you the the explanation I have now for benefits. You mean like currently?
[AGENT][NEUTRAL] No, so did Florida Blue process this claim?
[CUSTOMER][NEUTRAL] Well
[CUSTOMER][NEUTRAL] Yes, obviously, yeah.
[AGENT][NEUTRAL] OK, so that's what we need. We need a printout from Florida Blue that shows how they process this emergency room visit.
[CUSTOMER][NEGATIVE] But that's they don't, that's what I'm saying, that they're not keeping over 2 years backwards. That's what they're not keeping.
[AGENT][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] In the portal I also don't have access to that 2 years backwards. I think in the portal I have just for 1 year and they have just 2 years something like that.
[AGENT][NEUTRAL] OK, I
[CUSTOMER][NEUTRAL] 0, 18 months, I don't remember exactly.
[AGENT][NEUTRAL] They they should have record of all of your claims that have ever been filed if you're if you're with them, if you're a current member.
[CUSTOMER][NEUTRAL] Um, I, I, I, I, I did the, I checked. I mean they told me they don't. What can I do?
[AGENT][NEUTRAL] Well we have we have to have that information from Florida Blue. Do can they send you some type of documentation that shows how the claim was processed because that's what we have to have that's that's the requirement for this type of.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] And if the if the documentation coming from the hospital, which they tell you how they process it with Florida Blue.
[CUSTOMER][NEUTRAL] So, what's the problem if the hospital tells you how they process it with Florida Blue.
[AGENT][NEUTRAL] I, I can send it back through for review um with our claims department, but we, we always have to have the primary EOB that's a requirement for this policy. So the primary EOB would come from Florida Blue.
[CUSTOMER][NEUTRAL] Uh, uh, they just told me they don't have it over 2 years backwards. I mean, I don't know what to tell you. That's what they told me. That's what they told me to check with it. That's what I told you, and you told me to ask it from the hospital, but they'll give you with all the me with all the benefits.
[AGENT][NEUTRAL] Let me check something.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] With my son, it actually was more complicated because, because his hospital wasn't able to do it, but uh the Aventura hospitals where I went, they were able to do it.
[AGENT][NEUTRAL] I the notes that I have in here just states that we explained to you that we need the primary explanation of benefits. Um, let me see, what was your son's name? I can check on his claim as well.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, [PII].
[AGENT][NEUTRAL] And that, and what was his date of birth?
[CUSTOMER][NEUTRAL] Uh, [PII].
[AGENT][NEUTRAL] Yeah, and then it looks like the last thing we received from him was from [PII] and [PII]. Let's see what.
[AGENT][NEUTRAL] And we and that and that's the same thing. We need the explanation of the primary benefits.
[AGENT][NEUTRAL] So I, I guess, um, so the hospital should have a copy of that explanation of benefits cause that's what they receive too. They mail out.
[CUSTOMER][NEUTRAL] Yeah, that's what they sent you from the hospital. Yeah, that's what I sent you from the hospital. So if you're gonna look on my documentation, it's written in the, in the, the second time I submitted my claim, it's with all the details from the hospital.
[AGENT][NEUTRAL] Right, it has to be a sheet though that says.
[CUSTOMER][NEUTRAL] How they process it.
[AGENT][NEUTRAL] It says Florida Blue, it's from a document that actually comes from [PII]. It'll have their logo, um, and then showing how everything was processed.
[AGENT][NEUTRAL] So that's what I'm looking through here and I don't, I don't see that. Um, let me see.
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] Um.
[AGENT][NEUTRAL] One bill.
[AGENT][NEUTRAL] OK, give me just one moment, OK?
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] This is for [PII].
[AGENT][NEUTRAL] to deny for the first thing.
[AGENT][NEUTRAL] I
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, that doesn't tell us anything.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I see that.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] I see [PII].
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, sorry about that. um, so yeah, so the one for [PII].
[AGENT][NEUTRAL] That one for 1,296.
[AGENT][NEUTRAL] So you're your Florida blues.
[CUSTOMER][NEUTRAL] 1 1000.
[CUSTOMER][NEUTRAL] What?
[AGENT][NEUTRAL] Um, this one's for you. This is the claim that we're talking about.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] It's 300. It's not 1000. What? It was 300 something 350 I paid, not 1000.
[AGENT][NEUTRAL] OK, so there's in the 21 pages of documents we received, there's two charges here. There's one for the physician, the total charge was 1,296, which Florida Blue paid 100% of. So there's nothing left to reimburse on that.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] On the other charge, the 14,485, that looks like the facility charge for the actual hospital. There is no explanation of benefits in here. We don't have anything that shows how Florida Blue paid.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] We do see the receipt at the very end, which is not very legible, but it shows $300 paid with a Mastercard.
[AGENT][NEGATIVE] But it doesn't show us how.
[CUSTOMER][NEUTRAL] Yeah, yeah, that's mine, yeah.
[AGENT][NEGATIVE] Right, so there's nothing in this document of the 20 pages received that shows how Florida Blue or anything from Florida Blue. The only Florida Blue documents for that $1200 charge for the physician, which paid 100%.
[AGENT][NEUTRAL] So we're, we are missing that.
[CUSTOMER][NEUTRAL] OK, so if they didn't, OK, so if they didn't pay that $300 that's not what you're supposed to cover?
[AGENT][NEGATIVE] We need to see how Florida Blue processed the claim for $14,000. That's nowhere in these documents. It doesn't show how they processed it.
[CUSTOMER][NEUTRAL] You mean, you mean there are two charges? I just wanna understand there are two charges, 14 that I don't even know about it because they paid 100%. And the second one, which is 1200, which they paid about 900. That's what you mean?
[AGENT][NEUTRAL] No, there's 2 charges
[CUSTOMER][NEUTRAL] From what? From the number you see?
[AGENT][NEUTRAL] The first charge was 1296, 1,296, and that was for the ER doctor. Florida Blue paid 100%. You didn't know anything for that.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The second charge is for the hospital charges, which is 14,485.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] We don't have an explanation that shows how Florida Blue paid on this.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] So we don't know what to reimburse.
[CUSTOMER][NEGATIVE] Uh, so you can't, you don't see how they pay their like 1100, basically, that's what you're saying? You can see why they paid about 1100 because I paid just 300.
[AGENT][NEUTRAL] Yeah, we don't see how we have an explanation from Florida Blue for that ER physician charge, the 1296, but there's not one for the $14,000 charge. That's what we need.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] That shows how it
[CUSTOMER][NEUTRAL] So that's also the hospital they're supposed to have.
[CUSTOMER][NEUTRAL] Basically.
[AGENT][NEUTRAL] Right. There's always two charges when you go to the ER. It'll be for the doctor that saw you and then, for the actual hospital.
[CUSTOMER][NEUTRAL] So, for the doctor you have and for the facilities you don't have, that's what you're saying?
[AGENT][POSITIVE] Correct. Yes, that's correct.
[CUSTOMER][NEUTRAL] So I need to call back. Oh my God, [PII] and they need to give me their their explanation for the facilities, how Florida pay them.
[AGENT][POSITIVE] Yes, correct.
[CUSTOMER][NEGATIVE] OK, let me just write it down. It's because it's becoming insane. And for my son.
[CUSTOMER][NEUTRAL] Uh, what you're missing for him. I think for my son was a different father actually, whatever.
[AGENT][NEUTRAL] Uh,
[AGENT][NEUTRAL] Uh, let me see for him, let me get that pulled up real quick.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] for his claim.
[CUSTOMER][NEUTRAL] It's always so complicated or it's just with me like that?
[AGENT][NEUTRAL] Um, most of the time if you present your card, they'll just file it for you and then you don't have to, um,
[CUSTOMER][NEGATIVE] I know, yeah, that's the thing is that I never didn't know that I have that card until someone told me why I'm paying all that money, so I couldn't find just two charges whatever.
[CUSTOMER][NEUTRAL] OK, so for me, I need the facilities.
[CUSTOMER][NEUTRAL] Benefits and you said it was about 14,000 plus minus and I said and I paid $300 from what you see and I paid 300 for the 14,000 of the facilities I paid $300 that's what you see, right?
[AGENT][NEUTRAL] Yes,
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] That's was from a Ventura, OK, and for my son it was uh [PII] I believe, or no, I don't remember.
[AGENT][NEUTRAL] Um, so for him, it looks like we just got
[AGENT][NEUTRAL] It just shows the cost per pay period, how much the insurance costs. It doesn't give us like an itemization of what services were rendered.
[AGENT][NEUTRAL] Um, it just gives us a printout of your benefits, it looks like, which is not.
[AGENT][NEUTRAL] That, um, it just tells us what your benefit costs are, like, how much you pay for all your insurance services.
[AGENT][NEUTRAL] And then it showed just a simple breakdown of the charges. So we really need to see that the actual claim what what services were rendered, and then the Florida Blue explanation of benefits.
[CUSTOMER][NEUTRAL] No, I, I did send you the receipt for him from the hospital.
[AGENT][NEUTRAL] That one we just have and this is for um.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Yeah, remember they send me the receipt, that's for sure. What I paid.
[AGENT][NEUTRAL] Right, but we need
[CUSTOMER][NEUTRAL] Itemized receipts
[AGENT][NEUTRAL] We, we don't have, uh, so I see all of your, you sent us insurance documents that breaks down how much you pay for all of your group Aflac, uh, healthcare flexible spending account, health reimbursement account, gap insurance. Looks like a printout maybe from your employer.
[AGENT][NEUTRAL] It's it's got several pages of a printout from your employer. I don't know.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] No, but I also send you for him. I also send you for him uh the item I bill from the hospital itself.
[AGENT][NEUTRAL] Not seeing an itemized bill from the hospital. Let me see, let me double check. There's, like I said, there's several, several pages of your employer printout.
[AGENT][NEUTRAL] Let me check
[CUSTOMER][NEUTRAL] No, I'm not talking about them. The employer print out that that's I printed out myself. I'm not referring to that. I'm referring to what the hospital sent me.
[AGENT][NEUTRAL] We did get, um, uh, it just shows the dates of service, um, $719 but it doesn't show us any diagnosis. Um, so we have to have an actual itemization from the hospital that shows the diagnosis.
[AGENT][NEUTRAL] So it doesn't show that anywhere, so.
[AGENT][NEUTRAL] We don't know.
[CUSTOMER][NEUTRAL] Do you have an email? Maybe instead of just refiling the claim, I can email you and you'll tell me what I'm missing.
[AGENT][NEUTRAL] Um, we don't have an email to submit claims to.
[AGENT][NEUTRAL] You'd have to fax
[CUSTOMER][NEGATIVE] And not to submit a claim just to see if the to see if the the forms that I'm submitting are correct. I don't know what to submit anymore. I just submitted it twice. I don't know what to do anymore.
[AGENT][NEUTRAL] Well, you
[CUSTOMER][NEGATIVE] OK, I feel like you're exhausting me.
[AGENT][NEUTRAL] You, you need to call the healthcare provider and see if they can provide you with a like a claim that shows services rendered, the diagnosis code, cause that's, and then what Florida Blue paid on the claim.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, that's what I tried. That's why the blue told me that they don't have it.
[AGENT][NEUTRAL] That's
[CUSTOMER][NEUTRAL] Um
[AGENT][NEUTRAL] But the children's hospitals should have it, so they should have received explanation from Florida Blue cause they have to be mailed that information.
[CUSTOMER][NEUTRAL] I did try it then.
[AGENT][NEUTRAL] So they should have it on file.
[CUSTOMER][NEUTRAL] What's the name of the children's hospital?
[CUSTOMER][NEUTRAL] It will do the Maio.
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Bye.
[CUSTOMER][NEUTRAL] I'll probably able to. OK, fine. And I can just add it to a claim or I need to reopen all the claim and add all the documents. Can I just add these specific documents?
[CUSTOMER][NEUTRAL] Via the website.
[AGENT][NEUTRAL] Um, if you're on the website, on the portal, you'll have to start a new claim and then upload it from there.
[CUSTOMER][NEUTRAL] So I already have to start all new claim again.
[AGENT][NEUTRAL] Well we'll we'll review what you have on file we'll be able to match it with the documents that we have, but you can just simply upload the documents that we need and then we'll we'll be able to process it from there if we have everything we need.
[CUSTOMER][POSITIVE] OK, I OK, thank you.
[AGENT][NEUTRAL] OK. Is there anything else I can help with today?
[CUSTOMER][NEGATIVE] No thanks bye.
[AGENT][NEUTRAL] OK.