AccountId: 011433970860
ContactId: 2aedc052-a7d3-4a36-9d7d-100ce3f078cd
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 704799 ms
Total Talk Time (AGENT): 207130 ms
Total Talk Time (CUSTOMER): 319630 ms
Interruptions: 0
Overall Sentiment: AGENT=0.4, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/28/2aedc052-a7d3-4a36-9d7d-100ce3f078cd_20250428T18:05_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], um, let me give you my policy number.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It's 02496910.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] And may I have your name and a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] My name is [PII] and my phone number is [PII].
[AGENT][POSITIVE] Thank you for that and how may I assist you today?
[CUSTOMER][NEUTRAL] Hi, um, so anyway, I'm calling regarding, um, let me see.
[CUSTOMER][NEUTRAL] Claim number.
[CUSTOMER][NEUTRAL] 02, no, I'm sorry. OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] No, that's not it. OK, hold on. It's 358-027-5.
[AGENT][NEUTRAL] 8025. OK, here we go. And I just need you to verify your date of birth, your mailing and email address on file.
[CUSTOMER][NEUTRAL] [PII] um and then my email is [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. Let me pull that 1. 275.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so this claim was denied because the documents you received showed that your primary insurance paid all the benefits.
[CUSTOMER][NEUTRAL] OK, but I'm not talking about paying the benefits. I'm talking about, um, for example, the deductible amount.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Um, I don't know how you determine that, um.
[CUSTOMER][NEUTRAL] Those, those bills that you, I mean those explanation of benefits is whatever um.
[CUSTOMER][NEUTRAL] United States, but
[CUSTOMER][NEUTRAL] I, you know, that's after the deductible is met.
[AGENT][NEUTRAL] So you're trying to figure out why the claim was denied?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So there's two parts to it. OK, so,
[AGENT][NEUTRAL] For one of your codes here, that's what the the the reason was for that primary had paid everything, but for the other ones, it's asking you to present additional information. Um, let me see.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Um, OK, so we received your claim, however, in order to provide further consideration of this loss under the policy, we will need supporting documentation, um, to evidence that it that it was an accident or sickness. So there, so basically with what was sent in, there was nothing that showed a diagnosis, so the examiner can't tell if it's an accident or sickness. So they're just asking you to send in if you have that. Go ahead.
[CUSTOMER][NEUTRAL] So, uh,
[CUSTOMER][POSITIVE] I, uh, I'm sorry to interrupt you. I attached all those.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Um, proof on their claim number 3592599.
[AGENT][NEUTRAL] OK, so you then resubmitted it and this claim was paid. So the old claim is no longer valid.
[CUSTOMER][NEUTRAL] OK, so, but I, OK, so on that, um, paperwork that I submitted on their claim 3592599, um they were uh almost 22 days that I was in um.
[CUSTOMER][NEUTRAL] In that, um
[CUSTOMER][NEUTRAL] Hospital, right? So,
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] There is one.
[CUSTOMER][NEUTRAL] like accumulated bill from them with all the days that I was at the facility.
[CUSTOMER][NEUTRAL] OK, and that has amount you owe is $5,749.38.
[CUSTOMER][NEUTRAL] Then, um, I submitted each.
[CUSTOMER][NEUTRAL] Invoice separately for those days.
[CUSTOMER][NEUTRAL] In the accumulation statement that they sent.
[CUSTOMER][NEUTRAL] So it's not, I do see that there is a payment of $3,449.38.
[CUSTOMER][NEGATIVE] But I do see that there is a lot of days that are missing from this payment.
[AGENT][NEUTRAL] So from this,
[CUSTOMER][NEUTRAL] So, the day that I went.
[CUSTOMER][NEUTRAL] I'm sorry, go ahead.
[AGENT][NEUTRAL] You can continue.
[CUSTOMER][NEUTRAL] OK. So,
[CUSTOMER][NEUTRAL] I, I, I went to that facility on [PII], and I came out of the facility. My last day was [PII].
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Um, I do see in the payment.
[CUSTOMER][NEUTRAL] Um, let me pull it again, it closed, um, hold on.
[CUSTOMER][NEUTRAL] OK, so on the explanation of whatever APL is paying, um, I do see, um, that they paid $249.38 for the day from the.
[CUSTOMER][NEUTRAL] 227 to 228. OK. Then I do see 31.
[CUSTOMER][NEUTRAL] $400 and then 32 to 39.
[CUSTOMER][NEUTRAL] 2800.
[CUSTOMER][NEUTRAL] How about
[CUSTOMER][NEUTRAL] The days prior to those payments that you guys are making.
[AGENT][NEUTRAL] So there's 3
[CUSTOMER][NEUTRAL] What happened?
[AGENT][NEUTRAL] There are 3 lines on here with hospital charges. Let me pull up your explanation of benefits so I can see what you see. But there's 3 things here that are asking you to submit the explanation of benefits from your primary insurance. And once those are received, then we can pay out on the one that says [PII], and then there's one that says [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] And then for [PII], let me see why that one was denied.
[AGENT][NEUTRAL] It's a duplicate. So we're just missing the explanation of benefits from primary insurance and once we receive that, we can pay towards the hospital charges.
[AGENT][NEUTRAL] So anytime you submit or
[CUSTOMER][NEUTRAL] Do I submit it?
[CUSTOMER][NEUTRAL] I'm sorry, go ahead.
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] Do, so do I submit it on.
[CUSTOMER][NEUTRAL] The same claim or do I just send it on.
[CUSTOMER][NEUTRAL] A second claim.
[AGENT][NEUTRAL] So anytime you submit a claim in the online service center, it's going to show as if it's in another claim, but once the examiner, because it's a new entry, but once the examiner gets the documents, they'll be able to see that this is the requested or the additional information from such and such claim.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] So anytime a claim is submitted, you'll always need the explanation of benefits from primary, the claim form, and the itemized bill, because this is the secondary insurance, so we'll always need to see what primary did.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, I also submitted um.
[CUSTOMER][NEUTRAL] On the [PII], yeah, like Questa agnostics uh for claim 3594063.
[AGENT][NEUTRAL] And those are all asking for the explanation of benefits from primary insurance.
[CUSTOMER][NEUTRAL] OK, so I do see, OK, I'll go ahead and submit.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] The, um, I'll go ahead and send it from, you know, from my insurance, right? So just send [PII] and then she'll be able to figure out which one goes with what, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] The first, OK, alright, thank you. That's what I needed to know. Oh, and the other last question, the other last question, um, when you guys make the payments, do you mail, um, this to the facility or to me?
[AGENT][NEUTRAL] I
[AGENT][NEUTRAL] Um, it depends. It could be both or it could be one or the other. If there's something that's still owed to the provider, we would, we can pay it to them. If it's something that you've paid already, it would be a reimbursement to you, um, so it depends on what the paperwork shows.
[CUSTOMER][NEUTRAL] OK, so the payment.
[CUSTOMER][NEUTRAL] The payment that was sent with the $3800 was it, where was that sent?
[AGENT][NEUTRAL] Um, hold on one moment. That was claim number 358-0275?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Um, no.
[CUSTOMER][NEUTRAL] That is um 359-2599.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, it was sent to [PII].
[AGENT][NEUTRAL] So I sent to you.
[CUSTOMER][POSITIVE] OK, so it was sent, all right, so it was sent to me. OK. All right. Awesome. Thank you. I'll go ahead and um and submit the rest.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] See, you know, if.
[AGENT][NEUTRAL] Hello.
[CUSTOMER][POSITIVE] Hi, um, yes, I'll go ahead and submit the rest. Thank you so much.
[AGENT][POSITIVE] You're welcome. Well, thanks for calling APL and I hope you have a great day.
[CUSTOMER][POSITIVE] Thanks. Bye-bye.