AccountId: 011433970860
ContactId: 2ffa084f-8572-4e3e-a17f-3459c560e6f9
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1225479 ms
Total Talk Time (AGENT): 516032 ms
Total Talk Time (CUSTOMER): 462330 ms
Interruptions: 1
Overall Sentiment: AGENT=0.2, CUSTOMER=-0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/08/2ffa084f-8572-4e3e-a17f-3459c560e6f9_20250508T14:42_UTC.wav
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[AGENT][NEUTRAL] Good morning. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Yes hi um I was hoping that you can explain on some of the uh claims that was processed on my portal. I don't really understand, so I was hoping you can help me.
[AGENT][NEUTRAL] OK, sure, I can assist you with claims. Um, may I have your name and a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] Yes, my name is [PII] and the callback number is [PII].
[AGENT][NEUTRAL] Thank you. And may I have the policy number, Miss [PII]?
[CUSTOMER][NEUTRAL] 19756887
[AGENT][NEUTRAL] Thank you. And for security, may I have your date of birth, mailing address and email address on file?
[CUSTOMER][NEUTRAL] Uh, date of birth is [PII] address [PII], and um my email address, I'm not sure which one you have. I have my personal [PII] or [PII].
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, it's gonna be for your work email for the part, uh, work email.
[CUSTOMER][NEUTRAL] Which one do you have?
[CUSTOMER][NEUTRAL] Which which email address do you which email address do you have on file?
[AGENT][NEUTRAL] [PII], or email.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] OK, and you're still on.
[CUSTOMER][NEUTRAL] OK [PII] um it's with.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Go ahead.
[AGENT][NEUTRAL] OK, yeah, and you're still on [PII] for your address?
[CUSTOMER][POSITIVE] Correct, yes.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] All right. Let me pull your um
[AGENT][NEUTRAL] Explanation of benefits.
[CUSTOMER][NEGATIVE] Yeah, it's just so confusing.
[AGENT][NEUTRAL] OK, yeah, I understand.
[CUSTOMER][NEUTRAL] You guys keep asking for more information and I can't give you any information. The information is coming from my, my, uh, first medical UMR, so I don't know.
[CUSTOMER][NEUTRAL] I, I don't know.
[AGENT][NEUTRAL] OK. What claim are you looking at right now?
[CUSTOMER][NEUTRAL] Alright, let's, uh, I'm looking at the most three most current ones [PII]. The first one is claim number.
[CUSTOMER][NEUTRAL] 358-595-4
[AGENT][NEUTRAL] OK, let me pull an image on that one.
[AGENT][NEUTRAL] That's for [PII], so let's see.
[CUSTOMER][NEUTRAL] I, OK, that's for a brace, OK, so I guess that's not covered under the policy, so I think I know that one already. You guys don't cover, I guess.
[CUSTOMER][NEGATIVE] I broke my arm and you don't cover for the brace.
[AGENT][NEUTRAL] Let me make sure. Let me go ahead and just pull the image of the document.
[CUSTOMER][NEUTRAL] OK, it says durable medical equipment is not covered under this policy.
[AGENT][NEUTRAL] OK, and that is correct. Yes, I'm looking at the benefits and that is not covered under the policy. Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Going to the next one would be 358-867-5.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] OK, so on this one we have several.
[AGENT][NEUTRAL] Let me pull the image on this one.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] OK, so on this one, we need the diagnosis code uh for the date of service, [PII].
[AGENT][NEUTRAL] In [PII].
[CUSTOMER][NEGATIVE] OK, I don't understand when, when I don't understand what you're asking me on that one. This all you're my secondary APL is my secondary, um, medical insurance. UMR is my first, so I'm assuming that when I go to the doctors and I get service that it first goes through UMR and then whatever UMR doesn't pay, they're sending it to you so.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] I I don't understand why I'm responsible and getting all these diagnosis codes and paperwork. Isn't that what you should be getting from the first health insurance UMR?
[AGENT][NEUTRAL] OK, um, no, uh, the insurance don't send claims to another insurance company. Um, we don't process claims like that. Um, so basically, whenever you go to a doctor, to an office, to a hospital, um, you go in there, they go ahead and sending the claim to your primary insurance and if you have a secondary insurance, the provider, the hos
[AGENT][NEUTRAL] We'll send it to the secondary insurance together with the copy of the explanation of benefits from the primary insurance. That's how all the claims are processed, so they come directly from the provider of service. Um, in this case, it looks like you submitted the claim.
[AGENT][NEUTRAL] Is that correct?
[CUSTOMER][NEUTRAL] I'm not sure. I, I, I have so many claims going on right now. Um, I might have. Can you tell me what this was for because it doesn't give me any explanation.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm, mhm.
[AGENT][NEUTRAL] OK, so it looks like this was for a surgical center. Um, let me go ahead and pull the documents of the claim.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] No
[CUSTOMER][NEUTRAL] So this is for $224,722 was the total for this bill, is that correct?
[AGENT][NEUTRAL] Um, I had to pull the documentation. Uh, we don't have the total charge like that. Mm.
[CUSTOMER][NEUTRAL] OK, I just don't.
[CUSTOMER][NEUTRAL] I see the explanation. It says receipt of your claim is acknowledged. You need to provide further consideration. This policy.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] OK, so let me go to the next patient.
[AGENT][NEUTRAL] I just
[AGENT][NEUTRAL] OK, bear with me. I have to go through the documents.
[CUSTOMER][POSITIVE] No worries.
[CUSTOMER][NEGATIVE] I just don't understand any of it.
[AGENT][NEUTRAL] OK, well, basically, um, while I wait on these documents to upload, basically when you, whenever you send in a claim, which this is the case on this one that you submitted a claim that you send us a claim electronically through the website, um, whenever you submit a claim, um, we need, um, the diagnosis code. The diagnosis code is not gonna be on the primary EOB. It's gonna be from the primary um from the provider of service.
[AGENT][NEUTRAL] So that bill that you get from the provider of service, um, when it doesn't have the diagnosis code, you just need to call and let them know that you need an itemized bill with the diagnosis code for us to process the claim.
[CUSTOMER][NEGATIVE] Oh, but they're having, I tried that and they're having a hard time giving me that stuff. I, I just don't get it. I guess they change insurance companies and I don't.
[CUSTOMER][NEUTRAL] Let's see
[AGENT][NEUTRAL] OK, so on this one what we received was only the explanation of benefits from UMR which it doesn't have much information and the information that you see in our explanation of benefits is what we got and that's why it's not enough to process because it says um that it was a diagnosis.
[AGENT][NEUTRAL] The diagnostic X-ray. So that's what they're charging for, um, but we don't have like the diagnosis code letting us know why you had to have that um that x-ray, um, if it was due to chest uh pain or you know, the diagnosis code will let us know why you had that x-ray done.
[AGENT][NEUTRAL] So in this case, um, UMR doesn't have the diagnosis codes on their explanation of benefits. So you have to contact um the place of service which here it looks like it was um provider [PII] or [PII].
[AGENT][NEUTRAL] Um, so you need to contact that doctor and ask for an itemized bill diagnosis code just to let them know that you're trying to submit claims and you need this information to submit your own claim unless they want to submit the claim for you if they wanna go ahead and collect for you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, I'm just a little confused. So you, you got nothing from UMR with this claim, is that correct?
[CUSTOMER][NEUTRAL] Is that something that I submitted? I don't even remember now.
[AGENT][NEUTRAL] Yes, you, you send us the copies of UMR. So we have the copies of UMR which is your primary insurance. We got the explanation of benefits from UMR. Now, the explanation of benefits doesn't have all the information we need. So what we're asking for is an itemized bill from the provider, [PII].
[AGENT][NEUTRAL] So we can go ahead and process the claim.
[CUSTOMER][NEUTRAL] OK, what's the total on that, the 24,000?
[AGENT][NEUTRAL] Uh, no, this one that I'm looking at right now, because um there's several documents, but the one that I'm looking at right now is gonna be for the diagnostic X-ray done on [PII].
[AGENT][NEUTRAL] OK, and let me go to the other [PII] moment.
[CUSTOMER][NEUTRAL] I'm trying to look at that OK for.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Oh my [PII].
[CUSTOMER][NEGATIVE] This is absolutely absurd.
[AGENT][NEUTRAL] Do you still owe that amount? Do you?
[CUSTOMER][NEUTRAL] It really is. I, I don't.
[CUSTOMER][NEUTRAL] I'm sorry?
[AGENT][NEUTRAL] But do you still owe that amount that you want to call and have them submit the claim for you instead of you going through all the troubles of getting all the paperwork? Because if they send in the claim directly, they can send all the information we need. But whenever we receive the claim directly from the insured, the insurer needs to provide all the documents.
[CUSTOMER][NEUTRAL] OK, can you just, are we still on the 358-867-5 claim number, right?
[AGENT][NEUTRAL] Yes, we are, mhm.
[CUSTOMER][NEUTRAL] OK, and that was for how much was that? Can you have a total on that because I, I can't, I don't, I can't find it right now.
[AGENT][NEUTRAL] 2
[AGENT][NEUTRAL] OK, so that one was for $209.
[CUSTOMER][NEUTRAL] I'm trying to look at uh OK I got it.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And that's
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And they paid so I owe $30.31 it shows, right?
[AGENT][POSITIVE] Mhm. Correct. Yes.
[CUSTOMER][NEUTRAL] OK, why do I have a different confirmation number?
[CUSTOMER][NEUTRAL] I don't know why 473.
[CUSTOMER][NEUTRAL] I have
[CUSTOMER][NEUTRAL] Do you have the confirmation on that?
[AGENT][NEUTRAL] Um, when you say confirmation, you're talking about the claim number for UMR?
[CUSTOMER][NEUTRAL] No, it says the confirmation number is OSC 96472 on the portal, but I wrote down 473, so I don't know what that is.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] Let me see, let me go back to that. OSC 9, yeah, it's OK. OSC 96472 is under that claim.
[CUSTOMER][NEUTRAL] That's the thing there's so many.
[CUSTOMER][NEUTRAL] Yeah, but it's also under OSC 96473, correct?
[AGENT][NEUTRAL] 7373 is gonna be uh claim number 3589132. So that's a different claim.
[CUSTOMER][NEUTRAL] OK, that's not what I had written down on my paperwork, that's the thing, so.
[CUSTOMER][NEUTRAL] Alright, let me just confirm this is claim number 3588.
[CUSTOMER][NEUTRAL] 75.
[CUSTOMER][NEUTRAL] Right?
[AGENT][POSITIVE] Correct, yes.
[CUSTOMER][NEUTRAL] But the but the confirmation number is OSC 96472 not 3.
[AGENT][NEUTRAL] Correct, 72.
[CUSTOMER][NEUTRAL] OK, so that amount is $209 and so you need more paperwork. You need a.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] We need
[AGENT][NEUTRAL] Itemized bill with diagnosis code. Itemized bill with diagnosis code.
[CUSTOMER][NEUTRAL] What do you need?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So that's that one.
[AGENT][NEUTRAL] OK. OK. Under the same claim.
[CUSTOMER][NEUTRAL] And I submitted that myself, yeah.
[AGENT][NEUTRAL] You submitted that, yes.
[CUSTOMER][NEUTRAL] But I'm wondering
[CUSTOMER][NEUTRAL] Yeah, I wonder if if the if the doctor is going to submit that as well.
[CUSTOMER][NEUTRAL] I guess I was submitting it not knowing that they do that do that on their own.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] OK. I can check and see if we received a doctor's submission. One moment, let's see.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] I'm just so confused with this stuff.
[AGENT][NEUTRAL] OK. Well, they, you know what, they submitted the one for the, the highest one, which is um the one for 24,513. They did submitted that one. Let me just go ahead and make sure it's the same one, OK?
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] I think that's probably the next claim number I was gonna ask you about.
[AGENT][NEUTRAL] Yeah, OK, so the 5.
[AGENT][NEUTRAL] Let me look at that one, bear with me.
[AGENT][NEUTRAL] documents on this one.
[CUSTOMER][NEUTRAL] 3,594,420
[CUSTOMER][NEGATIVE] Yeah, it doesn't show.
[CUSTOMER][NEGATIVE] It doesn't show the um oh it says amount.
[AGENT][NEUTRAL] OK, so yeah, it is for this one.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] So this one, they were charged.
[CUSTOMER][NEUTRAL] 24,513.
[AGENT][NEUTRAL] Yes, 2, 245,130.
[CUSTOMER][NEUTRAL] That's the one we're talking about?
[CUSTOMER][NEUTRAL] OK, yeah, that.
[CUSTOMER][NEUTRAL] OK, yeah, that is claim number. OK, so the doctor provided that, right?
[AGENT][NEUTRAL] The doctor sent us the claim and we went ahead and send that $500 directly to them.
[CUSTOMER][NEUTRAL] To them.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Why to them?
[AGENT][NEUTRAL] Because they submitted the full claim.
[CUSTOMER][NEUTRAL] OK, but I think that belongs to me, right?
[AGENT][NEUTRAL] Have you already paid that $500 to them?
[CUSTOMER][NEUTRAL] Yeah, I paid, I paid $500 copay to the doctor and $1100 before my surgery. That's why I'm trying to collect that money back into my pocket.
[AGENT][NEUTRAL] Oh, OK. OK. So, yeah, you will have to check with them because they did send in the claim and we send the payment directly to them. I can give you the details, which is the same information that you're looking at on the website. We processed on [PII] and send the check out for that amount, for the $500.
[CUSTOMER][NEUTRAL] OK, so that's all you've gotten from them so far.
[AGENT][NEUTRAL] Yes, that's the only one we have received and processed. So the only one that um then we have uh we're waiting on information is gonna be for the X-ray. The X-ray for $209.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh yeah yeah yeah yeah.
[CUSTOMER][NEGATIVE] It's so confusing.
[CUSTOMER][NEUTRAL] And the woman at this in my doctor's office, she just doesn't know what's going on I guess like I said, they changed, they changed.
[CUSTOMER][NEUTRAL] I don't know their insurance stuff.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEGATIVE] Alright, hang on, that was denied.
[CUSTOMER][POSITIVE] All right honey, well thank you so much for helping me out on that one I'm just gonna have to call the doctor's office and find out what's going on.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah. Like I said before, you can go ahead and ask them to see if they can submit the claim directly, but if they cannot for any reason, just ask them to send you or how to get a copy of the itemized bill with the diagnosis codes, OK?
[CUSTOMER][NEGATIVE] Yeah, I've tried that and it didn't work.
[AGENT][NEUTRAL] Oh.
[CUSTOMER][NEGATIVE] That's my frustration.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] I see, but you can get either of the ones that are listed in the back, um, so if you cannot get an itemized bill, you can get the super bill, you can get the office note, um.
[CUSTOMER][NEUTRAL] All right.
[AGENT][NEUTRAL] Or the summary. Well, that's the discharge summary which she was not in the hospital. So yeah, you can get the super bill or the office notes that has the diagnosis code if you cannot get an itemized bill, OK?
[CUSTOMER][NEUTRAL] Yeah, she, she printed out all these office notes for me too.
[CUSTOMER][NEUTRAL] I'm trying to go through them.
[AGENT][NEUTRAL] So you have a copy of the office notes?
[CUSTOMER][NEUTRAL] Um, I do, but boy.
[CUSTOMER][NEUTRAL] Let's see here, hang on one second, uh, I don't know if it says anything about that X-ray.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Oh yeah, diagnosis X-ray data [PII].
[AGENT][NEUTRAL] and this one is [PII].
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Well, that's probably when they processed it.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I'm sure they took different X-rays at different days, yeah, it says service date I see what you mean.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Uh, yeah, this woman gave me like all this paperwork and I'm like what are you supposed, what am I supposed to do with this stuff? Like, isn't that your job?
[CUSTOMER][NEGATIVE] So I feel like I pay so much for insurance and I'm doing all the work.
[AGENT][NEUTRAL] Yeah, usually the claims come from the providers, so the providers are the ones that needs to send that um we only process claims as we get them, yeah.
[CUSTOMER][NEUTRAL] Alright, I'm just
[CUSTOMER][POSITIVE] Yeah, I'm just gonna call her, ask her why she, you know what, OK, all right honey, thank you so much I'm sorry I just um.
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] It's just been a nightmare.
[AGENT][POSITIVE] I understand. It's OK. Is there anything else I'm gonna help you with today? Any other questions or concerns, Ms. [PII]? You're welcome and thank you for calling ATL. You're welcome. Have a good day.
[CUSTOMER][NEUTRAL] Alright
[CUSTOMER][POSITIVE] No, they'll do it thank you.
[CUSTOMER][POSITIVE] That's it thanks.
[CUSTOMER][NEUTRAL] Alright bye bye you too.
[AGENT][NEUTRAL] No.