AccountId: 011433970860
ContactId: 246729f2-26f2-4060-9942-98256e72b3d8
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 733299 ms
Total Talk Time (AGENT): 282185 ms
Total Talk Time (CUSTOMER): 287337 ms
Interruptions: 2
Overall Sentiment: AGENT=0.4, CUSTOMER=-0.9
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/29/246729f2-26f2-4060-9942-98256e72b3d8_20250429T15:19_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], I had a question. Um, I had filed a claim for my husband who recently had surgery.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] And um I was wanting to see if you can look into the account um the amount to be paid out seems um extremely low, lower than I thought it would be, and I was wanting to see if that was the final payment and if I submitted all the paperwork correctly.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, let's take a look. Do you have the claim number, policy number?
[CUSTOMER][NEUTRAL] Yes, let me, oh, I was just in there where, where is it? Sorry, I kinda came back out and.
[AGENT][NEUTRAL] No, that's OK.
[CUSTOMER][NEUTRAL] Uh, let's
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Trying to get back to my main.
[CUSTOMER][NEUTRAL] I'm so sorry. I just, I can't figure out how to get back to my dashboard. Let me just get back in and start over, OK.
[AGENT][NEUTRAL] No.
[AGENT][POSITIVE] Yeah, no, totally fine.
[CUSTOMER][NEUTRAL] Um, my, you were wanting the claim number? Oh, here it is, uh, mhm.
[AGENT][NEUTRAL] If, or, yeah.
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] Uh, policy number is 261.
[CUSTOMER][NEUTRAL] 663 9
[CUSTOMER][NEUTRAL] And I do have a claim number if you want that as well.
[AGENT][NEUTRAL] OK, what was the claim number?
[CUSTOMER][NEUTRAL] 359-472-0
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, and then on the policy, I will need to verify your name and date of birth, please.
[CUSTOMER][NEUTRAL] Mhm [PII] [PII].
[AGENT][NEUTRAL] Thank you, [PII] and then I need to verify please your um physical address.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm [PII].
[AGENT][POSITIVE] All right, thank you.
[AGENT][NEUTRAL] OK, so.
[AGENT][NEUTRAL] to pull your policy here.
[AGENT][NEUTRAL] OK, so it looks like it's sent.
[AGENT][NEUTRAL] A benefit payment for $600.
[CUSTOMER][NEUTRAL] And what exactly is that for the 600?
[AGENT][NEUTRAL] Well, all it looks like.
[AGENT][NEUTRAL] It's just showing University of Kansas Hospital and then a procedure code let me see.
[AGENT][NEUTRAL] It looks like it was the surgery itself, the procedure. I'm looking on your actual policy to see what your benefits.
[AGENT][NEUTRAL] Benefits are here, um.
[AGENT][NEUTRAL] So the other denials look like it's reading that this was the max benefit payment for the state of service um.
[AGENT][NEUTRAL] So there was nothing else additional required as far as like itemized bills or anything like that. Looks like you submitted everything that was needed. It's saying maximum benefit payable um when I looked down in the uh scheduled benefits as far as the repair that was done.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It looks like the plan itself just pays a percentage of the surgical, you know, um, what was done. And so that percentage was figured out based off of what you had sent in and that was the max payment, it looks like.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, so the 1310 I believe was the the amount.
[CUSTOMER][NEUTRAL] I just feel like that isn't correct, but I have to be if that's what they sent me.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEGATIVE] I just that that just can't be correct. The $655 that the a surgeon would bill and the anesthesiologist.
[CUSTOMER][NEGATIVE] This just doesn't seem correct.
[AGENT][NEUTRAL] Or what they
[CUSTOMER][NEGATIVE] At all, there's no way.
[AGENT][NEUTRAL] What they build you're saying?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEGATIVE] Yeah, this can't be correct. I looked at it and I was like this is something isn't right like.
[CUSTOMER][NEUTRAL] I can see there's just no way as a doctor only charged $655 for the surgery.
[CUSTOMER][NEUTRAL] You know what I mean?
[AGENT][NEUTRAL] No, well, I mean, I see one charge is $8,138 and then there was a charge for 6, yeah, $655.55 dollars.
[CUSTOMER][NEUTRAL] And that's
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Well, so that, um,
[CUSTOMER][NEUTRAL] The, the first bill, or actually let me the, yeah, my first bill on page 4, the KU Midwest Ambulatory Surgery.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So that that $8000 is for um the surge center itself.
[AGENT][NEUTRAL] Mm, mhm.
[CUSTOMER][NEGATIVE] And so we had to pay $3,947 before we could even have the surgery like right when we got there so we paid $3000 so we don't get any money back from that actual facility from from you all.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] So, yeah, I mean, on this, it looks like for the surgery, they're showing that, yeah, that was the highest percentage that they were gonna pay on this. Do you guys have any other insurance or just this?
[CUSTOMER][NEGATIVE] This, but I think I feel like the bill is not correct. Like I gotta find out something because it's like is this $8000 for everything and so you got in.
[CUSTOMER][NEUTRAL] You guys are paying the percentage off of what the 1839 or the 1310?
[AGENT][POSITIVE] That's a good question. I think it would be off of.
[AGENT][NEUTRAL] Let me see if I can match this. Give me just a second.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] I just don't feel like this is correct at all, this doctor's bill.
[CUSTOMER][NEGATIVE] Gosh, we have paid out so much money on the, on the surgery. It's just like what is the point of having insurance?
[AGENT][NEGATIVE] Um, that's not right. Give me just a second.
[AGENT][NEUTRAL] So, um, [PII], you know, if you want to, I can get a claims examiner on the line if you wanna talk to somebody that processes claims. And looking at the like schedule of operations, it seems like it was a repair to like a tendon.
[AGENT][NEUTRAL] Um, or something like that. And so it shows percentage of maximum surgical benefits, excuse me, at 6%. And so if I take that amount, the 8,138 plus the 655 twice, that gives us 9,448.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 6% of that is about $566 so.
[CUSTOMER][NEUTRAL] Got it.
[AGENT][NEUTRAL] That's just me mathing based off of what I see on the schedule of operations and you know um.
[CUSTOMER][POSITIVE] Wow.
[CUSTOMER][NEUTRAL] You know, I think what I need to do first is verify the if that is correct for the.
[CUSTOMER][NEUTRAL] What the surgeon and the anesthesiologist build.
[AGENT][NEUTRAL] OK. OK.
[CUSTOMER][NEGATIVE] Because to me that just seems extremely low.
[AGENT][NEUTRAL] Right, I mean, if it, yeah, I mean if there's something that is incorrect, yeah, if it needs to be resubmitted or submitted you can do that that's not an issue.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] You see what I mean?
[CUSTOMER][NEUTRAL] OK, OK, yeah, I think that's what I need to do because I, I seen that and to me I thought OK well you know, to me there's just no way that that just seems so low um.
[CUSTOMER][NEUTRAL] But I could be wrong, but I, I just, I don't, I don't think so but my other question was, um, what is a wellness claim because he has had so many um.
[CUSTOMER][NEUTRAL] Doctor's appointments and X-rays on this, um, and I've never seen a wellness claim before. It, what, what exactly is a wellness claim?
[AGENT][NEUTRAL] Mhm, mhm, mhm.
[AGENT][NEUTRAL] So wellness claim would be um if you're going for like your yearly um physical or um like for us as women, we have our yearly mammogram if we're at that age, that's a wellness visit and you can be reimbursed for that.
[CUSTOMER][NEUTRAL] Oh, OK, um, so like your OBGYN that type as well?
[AGENT][NEUTRAL] Mhm. Like, like your, yeah, your yearly Pap would be considered a wellness visit, a mammogram, uh, for men, if they, you know, are at the age where they have to have a yearly like colonoscopy, like that's a wellness, um, any sort of physical would be a wellness. Mhm.
[CUSTOMER][NEUTRAL] Oh OK well I just had all of this, so do I just submit, um, I just do the same and get an itemized bill of what they um charged my insurance or?
[AGENT][NEUTRAL] Yeah, so.
[AGENT][POSITIVE] Mhm, mhm, absolutely, yeah, and then you can submit those your um each person on the plane is eligible for one year.
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] All right, well let me follow up on this and get all.
[CUSTOMER][NEUTRAL] My paperwork and see what um if that is correct if so then then so be it um and if not I'll just um.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, put another or call in and see what I need to do to to fix it.
[AGENT][NEUTRAL] OK, not a problem, [PII]. Anything else I can check on?
[CUSTOMER][NEUTRAL] Uh, no, that's it.
[AGENT][POSITIVE] All right well thanks for calling I hope you have a good rest of your day.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] You too thank you bye.
[AGENT][NEUTRAL] Bye-bye.