AccountId: 011433970860
ContactId: 1a9f7aa8-7633-400a-887b-85a26f7f6403
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 933320 ms
Total Talk Time (AGENT): 313592 ms
Total Talk Time (CUSTOMER): 406597 ms
Interruptions: 1
Overall Sentiment: AGENT=0.4, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/19/1a9f7aa8-7633-400a-887b-85a26f7f6403_20250219T20:04_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling American Public Life. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi there, my name is [PII]. Uh, I'm calling, uh, to check on some claims that I have, uh, uh, for the gap insurance.
[AGENT][NEUTRAL] May I have a callback number please?
[CUSTOMER][NEUTRAL] Yeah, [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And may I have the policy number?
[CUSTOMER][NEUTRAL] Yes, uh, it is 02496462 ML 7.
[AGENT][NEUTRAL] And could you please verify your date of birth?
[CUSTOMER][NEUTRAL] That is [PII].
[AGENT][NEUTRAL] And I do need to verify the mailing address and email address on file.
[CUSTOMER][NEUTRAL] Absolutely, the mailing address is [PII].
[CUSTOMER][NEUTRAL] And the email should be [PII].
[AGENT][NEUTRAL] OK, and that is, and thank you so much for verifying the policy you're calling in regards to some claims. Do you have that date of service or claim number?
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Um, it's pretty much all the claims that are on the account. I did them relatively on the same at the same time. Um, I could provide one of them if you'd like, um.
[CUSTOMER][NEUTRAL] Uh, specific, the claim number that I have here is 356-562-7.
[AGENT][NEUTRAL] OK, so I did pull that claim up. How may I assist you on that claim?
[CUSTOMER][NEUTRAL] So I just wanna, so pretty much all the other claims are, are what seems to be like the similar status, but I guess my confusion lies at how do I know if the claim has been completed, uh, because basically what it says here on my status is that it's been processed. I don't know if that signifies that it's, it's pretty much completed uh I don't know if, yeah, like I don't know if it's been processed and there's no amount approved.
[CUSTOMER][NEUTRAL] Uh, or how that works, which, uh, obviously if.
[CUSTOMER][NEGATIVE] You know, it is, I guess if it's processed, my concern is if it is processed and completed and the amount paid is zero, I find that hard to believe considering um.
[CUSTOMER][NEUTRAL] All the like everything I submitted and all that, but I, I guess I wanted to just gain clarity on what the status is and why it says what it says.
[AGENT][NEUTRAL] OK, so it looks like the claim has just been processed and reviewed by an examiner today.
[AGENT][NEUTRAL] So that is the reason why that claim those the claims do have a claim number if there is a claim number generated that shows that that that process has processed that claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Now if it's showing a zero balance that's indicating that that claim either denied for some more needed documentation or it was not covered under this policy, but looking at this claim that you did give me, it is stating that it is requesting diagnosis codes and or procedure codes for this.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and how could I obtain that information?
[AGENT][NEUTRAL] For the diagnosis code or procedure, you will get that from the provider. So you will have to contact them and get that from them. It can either be on an itemized bill or a discharge paper, but it's gonna have to have the letter here from that provider listed.
[CUSTOMER][NEUTRAL] So you have to have, OK.
[CUSTOMER][NEUTRAL] OK, can.
[AGENT][NEUTRAL] And it will have to be for each date of service. So anytime when you submit any claim, we're gonna have to need that diagnosis code from the provider.
[AGENT][NEUTRAL] The, if it's for a facility, um, we'll have to have the diagnosis code or the discharge papers.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Sometimes the discharge papers for the facility will have that information listed.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, can we take a look at uh this next claim, um, the claim number is 356-562-1.
[AGENT][NEUTRAL] So for this one is showing that the primary insurance paid that amount in full.
[AGENT][NEUTRAL] So it did not show anything was applied to your deductible co-insurance or co-pay.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] 1 2nd.
[CUSTOMER][NEUTRAL] OK, and then.
[CUSTOMER][NEUTRAL] For this one which is 356 5.
[CUSTOMER][NEUTRAL] 556.
[CUSTOMER][NEUTRAL] I'm sorry, my apologies, 356-561-1.
[AGENT][NEUTRAL] So for this one it is showing that.
[AGENT][NEUTRAL] The primary insurance did not cover for the date of service of [PII].
[AGENT][NEUTRAL] And then for the date of service of [PII], it is showing that we're needing the hospital bill or the itemized bill for those dates of service.
[CUSTOMER][NEUTRAL] So I need to, I need to basically present the Jackson uh medical bill.
[AGENT][NEUTRAL] Yes, we're gonna have to have a hospital bill that is going to show the procedures, the dates of service or anything listed for that because we're gonna have to have the admission and discharge dates and time. So that's why we are requesting the itemized statement from the hospital.
[CUSTOMER][NEUTRAL] OK, so give me one second. I'm just writing this down.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] 356-561-1.
[CUSTOMER][NEUTRAL] Needs
[CUSTOMER][NEUTRAL] Hospital discharge.
[CUSTOMER][NEUTRAL] And uh
[CUSTOMER][NEUTRAL] 0.
[CUSTOMER][NEUTRAL] No, OK.
[CUSTOMER][NEUTRAL] Uh, and then for the following, uh, 356-577-1.
[AGENT][NEUTRAL] So it is showing for the office visit that it is not covered.
[AGENT][NEUTRAL] And then for the office procedure we're needing the diagnosis and or procedure codes for this. So any claim, if it doesn't have the diagnosis code, procedure code or any of that, that would have to be submitted into us and as stated before with the facility we have to have an itemized or a discharge papers.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] How would I be able to obtain the diagnosis and procedure, uh, information? That would all be on the itemized bill on behalf of whatever hospital was, uh, it was that serviced, uh.
[AGENT][NEUTRAL] If it's for the facility, normally it would indicate on the discharge paper the reason of that visit, but if it's for a physician bill, you would have to contact that provider.
[AGENT][NEUTRAL] And since these claims was processed today, you may receive the EOBs, you will be able to download those. You would normally have to give about 24 to 48 hours before that EOB is entered into the system.
[CUSTOMER][NEUTRAL] And my
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, so, so, uh, uh, two questions. When you say provider, you mean, um, the actual place that was visited, not, not, for example, not the insurance provider, correct?
[AGENT][NEUTRAL] You will contact the physician that rendered the services.
[CUSTOMER][NEUTRAL] I understand. OK, so if it was Quest and Quest, if it was you health then you health, if it was Jackson and Jackson, so on and so forth.
[AGENT][NEUTRAL] Yes, so whoever now normally like with Quest, the provider that is sending you over there, you can contact them and ask them for the information because a lot of times Quest may not have that diagnosis code, but you can contact the provider that is requesting for you to have that services or testing done.
[CUSTOMER][NEUTRAL] Not
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So I need, so realistically, I always need some diagnostic codes slash procedure codes.
[CUSTOMER][NEUTRAL] And then also an itemized bill, uh, so now the, the second question I had was in the case that I go, so I'm going through this process now and like you said.
[CUSTOMER][NEUTRAL] In 24 to 48 hours I'll receive an EOB such and such. Well, I also have the opportunity, so basically in the 24 and 48 hours that I wait and it tells me it was denied because this, this, this is required, would I be able to upload the documents that it needs me to upload, uh, on that same claim or would I have to do a completely new claim?
[AGENT][NEUTRAL] There you would have to upload a completely different claim. It won't let you combine those claims together.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Now just make sure when you're submitting any claims as stating you would need diagnosis, itemized or discharge papers, you would have to have that primary explanation of benefit that does show that you have a patient responsibility applied to your deductible co-insurance or co-pay. If that is not listed on there, it could be denied.
[AGENT][NEUTRAL] Requesting a detailed EOB.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so, OK, so as long as, as long as it shows that I have a copay and then I upload the rest of those things that you said, that is all that's required, understood. How do I?
[AGENT][NEUTRAL] Yes, as long as it has the co-pay, deductible or co-insurance, not just copay, it's gonna have to show your patients responsibility in those columns.
[CUSTOMER][NEUTRAL] So like for example on the on on that document where I sent you that it has uh the that pie chart where it has uh plan allowed amount plan paid patient responsibility under patient responsibility ultimately it would have to show a number uh that's that's what it would have to show.
[AGENT][NEUTRAL] Even though it says patient's responsibility is gonna have to indicate co-pay, deductible or co-insurance. Because see, a lot of times it can say patients responsibility and your primary did not cover it.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So it's gonna have to indicate those wording copay, deductible or co-insurance.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] So it's gonna have to have that as well it's interesting, OK.
[CUSTOMER][NEUTRAL] Alright.
[AGENT][NEUTRAL] And is there anything else that I can assist you with today, Mr. [PII]?
[CUSTOMER][NEUTRAL] Uh, I see.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][POSITIVE] No, no, uh, yeah, I think you've been a great help, uh, this, this, uh.
[CUSTOMER][NEUTRAL] Just give me some clarity, um.
[CUSTOMER][NEGATIVE] This is not so.
[CUSTOMER][NEGATIVE] OK, yeah, I got a. I was just looking at another bill there that shows that my plan didn't even pay for anything, which shouldn't be the case. That's why I said that.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][POSITIVE] Um, yeah, no, this is, this has been good help, so I'll, I'll, I'll move forward with being able to get, uh, all that stuff.
[CUSTOMER][NEUTRAL] Um, for all those claims and, and then what I'll do is I'll resubmit a claim.
[CUSTOMER][NEGATIVE] Uh, and then call back and make sure I have all the right information. I, I, to be honest, it was just I'm a little bit discontent because I had called before and I had asked if all I needed was the information that I provided and I was told yes, so.
[CUSTOMER][MIXED] Kind of sucks that I gotta do it again, but it is what it is, I guess.
[AGENT][NEUTRAL] OK, cause I do see some of them where they did go in as long as the primary insurance didn't cover it or if they paid it in full it was processed compared to what we received on the EOB but the other needed documentation like for the facility, we're gonna always need that information to know if it was for inpatient, outpatient or any of that.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK, uh, yeah, I'm not, definitely good to know now. Yeah, I mean, I, as far as the ones that got paid in full by my, my, my, my initial insurance by Amed, that makes sense because, you know, there's not really much that the gap insurance would have to cover so it's easier to process, but it makes sense what you're saying as far as the getting the diagnosis codes and all that stuff to be able to, to, to have that on your end. So I'll work towards getting that. Thank you.
[AGENT][POSITIVE] You're welcome and I do wanna thank you so much, Mr. [PII] for calling American Public Life. You have a great rest of your day.
[CUSTOMER][POSITIVE] Thank you you too.
[AGENT][POSITIVE] Thank you bye.