AccountId: 011433970860
ContactId: 33f57549-0465-4e98-8393-93d790d9772e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 766820 ms
Total Talk Time (AGENT): 272389 ms
Total Talk Time (CUSTOMER): 321737 ms
Interruptions: 1
Overall Sentiment: AGENT=0.5, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/01/33f57549-0465-4e98-8393-93d790d9772e_20250401T16:24_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yes, hi, [PII], um, my name is [PII]. I have spoken with [PII] earlier, um, and she asked me to speak with my provider Aetna.
[CUSTOMER][NEUTRAL] Um, to follow up on, on a claim, but now Aetna circled me back to you guys, so I wanted to discuss, uh, a claim that was already processed on your end, uh, on your end recently for MD now on a [PII] visit.
[CUSTOMER][NEUTRAL] Um, where there was no payment, um, paid out, and I think it had something to do with maybe, um, how it was filed, etc.
[AGENT][NEUTRAL] Um, yes, ma'am. I can assist you with claim status.
[CUSTOMER][NEUTRAL] And I'm just
[CUSTOMER][NEUTRAL] OK, so I'm trying to follow up on the $85 that was charged to me at the time of my visit because they couldn't um get approval for the code that they were entering for APL coverage, so they had me pay um a co-pay, but that technically should have been covered by my gap insurance by the APL.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] OK. Yes, ma'am. Could I first get a callback number just in case we're disconnected?
[CUSTOMER][NEUTRAL] Yes, [PII].
[AGENT][NEUTRAL] OK. Thanks, [PII]. And now, could I get your policy number, please?
[CUSTOMER][NEUTRAL] Uh yes, it's um 024.
[CUSTOMER][NEUTRAL] 055
[CUSTOMER][NEUTRAL] 22.
[AGENT][NEUTRAL] OK, thank you. Now, please verify your first and last name and your date of birth.
[CUSTOMER][NEUTRAL] [PII] [PII]
[AGENT][NEUTRAL] And please verify your mailing address and your email address.
[CUSTOMER][NEUTRAL] Email is [PII].
[CUSTOMER][NEUTRAL] And my address is [PII].
[AGENT][NEUTRAL] OK, and I'm showing that you don't have an email address on file. Would you like for me to add that one?
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] And what's the, uh please repeat it.
[CUSTOMER][NEUTRAL] Yes, it's uh [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, I've added your email address and what's the date of service and bill charges for the claim you're calling about?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] What was the other question you have for that?
[AGENT][NEUTRAL] OK. Yes, ma'am. I found the claim in our system and what I'm doing now is opening up the image to take a look at what uh we've received and why the claim um did not pay out.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] I think on your end, according to [PII], it seemed that the claim was already paid by Aetna, but what was not covered is the co-pay of $85 which I paid on the day of the visit.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] OK. Thanks for your patience. And yes, ma'am. That's what we're showing. We're showing that Aetna paid the um $85. So it looks like you would need to um do what the prior representative said and go to Aetna because it looks like um Aetna. OK, and they sent you back to us?
[CUSTOMER][NEUTRAL] I did.
[CUSTOMER][NEUTRAL] Yeah, they, they didn't, yeah, they, yeah, because they didn't pay it. I, I have a, um, the billing invoice and it shows that um my responsibility is 85 and I have a receipt for the 85 because I paid it at the time of the visit, so they sent me back to you.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. Yes, ma'am. I apologize because we can't go by that receipt. We can only go by what Aetna says. And according to the documentation, what we have so far, the only documentation we have is the EOB from Aetna saying that they covered it. Now, if um Aetna can produce another explanation of benefits showing where they did not cover it, and you did cover it, then you can submit that and we'll pay you directly.
[AGENT][NEUTRAL] But we have to have an explanation of benefits that Aetna um did not pay it because according to what we have, they did pay it.
[CUSTOMER][NEUTRAL] OK, so
[CUSTOMER][NEUTRAL] OK, so then let me ask you a question. How do I, how do I get this done? Do I have to go back to Rena and tell them they want an explanation of benefits and they have to send that to you?
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Well, Aetna won't send it to us, um.
[CUSTOMER][NEUTRAL] Or can I make a claim myself?
[AGENT][NEUTRAL] Yes, you can make a claim yourself, but you would have to get the EOB, you would have to get the explanation of benefits from Aetna showing that they did not make this payment. And once you get that EO explanation of benefits from Aetna, you can submit the claim yourself and we'll pay you.
[AGENT][NEUTRAL] Directly and you can submit the claim um either online, you can mail it to us or you can fax it to us and I can let you know how to do that now or you can wait till after you get the documentation from Aetna and give us a call back and we'll be glad to show you how to submit the documentation to us so we can pay you.
[CUSTOMER][NEUTRAL] OK, so I'm
[CUSTOMER][NEUTRAL] OK, so, OK, so I'm on the Aetna website and the EOB statement. I have, um, I did just downloaded the EOB statement, so what would you, yeah, it shows on the EOB statement it says your payment summary, um, it says your share $85 on there, um, and it gave um.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And can I ask you a question? What's the, uh, what's the adjudication date of the explanation of benefits that you're looking at?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Explanation, um, it shows statement date is [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, great, because the one that we have, the one that we have is showing [PII]. So the one you have is showing [PII]. It's showing that it's updated. So yes, we can, it sounds, it's, well, I can't make any promises, but according to what you're saying, it sounds like we can use that EOB to reprocess this claim.
[CUSTOMER][NEUTRAL] For the sun, yeah.
[CUSTOMER][NEUTRAL] Uh, OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so then how do um I make that claim with you then? I go to your website?
[AGENT][NEUTRAL] Yes, ma'am. You can go to our website. Let me give you our website.
[AGENT][NEUTRAL] Let me know when you're ready.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] I'm ready.
[AGENT][NEUTRAL] Um, it's [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And when you go there,
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Um, yeah, [PII].
[AGENT][NEUTRAL] OK. And you should see a blue button that says new user or it may say register here.
[CUSTOMER][NEUTRAL] OK, so yeah, I'm gonna, OK, submit my name is there already in my password.
[CUSTOMER][NEUTRAL] OK, I'm in there so then I go to claim form.
[AGENT][NEUTRAL] Well, do you see where it says upload documentation?
[CUSTOMER][NEUTRAL] Yeah, upload files, yes.
[AGENT][NEUTRAL] Yes, ma'am. You'll go there and that's where you'll upload the um Aetna, the, the updated Aetna EOB and if you can, you can also make a note on the um EOB just letting us know that this is the updated claim and I can give you the claim number. But once we receive it, we'll know that that's um new documentation for this claim to be reprocessed.
[CUSTOMER][NEUTRAL] Oh, OK, because right now it's asking me to complete my name and information. Um, it didn't give me an easy access. I have the link upload file, but there's a different way of going about adding, I guess. Uh, let me just see, um, OK, so what's the next thing after this?
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] OK, upload files. OK, I entered my information. Now I can upload the file.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, now the file, um, let me just rename it. Let me put Aetna A E T N A statement dated [PII].
[AGENT][POSITIVE] And I can give you
[CUSTOMER][POSITIVE] OK, perfect.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And I, I can't drag and drop, right?
[AGENT][NEUTRAL] No, ma'am.
[CUSTOMER][NEUTRAL] I have to actually do select file OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, it's a PDF so you a PDF, right?
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK, so I uploaded but it doesn't allow me to add a message, but it is the, the statement is dated at least the reference on the name automatically put it as of um [PII].
[AGENT][NEUTRAL] OK. Yeah, we can look at the dates on the claim.
[CUSTOMER][NEUTRAL] Confirmation
[CUSTOMER][NEUTRAL] Oh, OK, so the confirmation number I received was 0S as in Sam, C as in Charlie 95886.
[AGENT][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] And it shows in the claims my claims section that it's been uploaded.
[AGENT][NEUTRAL] OK. It's not showing up yet, but if you have the confirmation number, it will eventually show up sometime today, and we just ask that you allow 7 to 10 days for processing. Mhm. Yes, ma'am.
[CUSTOMER][NEUTRAL] Oh, on your end OK.
[CUSTOMER][NEUTRAL] OK, so will that happen automatically based on that claim or I have to actually um do a claim form?
[AGENT][NEUTRAL] No, you wouldn't have to fill out a claim form. We can um use the updated explanation of benefits from Aetna.
[CUSTOMER][NEUTRAL] OK, yes, OK.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK. Is there anything else that I can assist you with?
[CUSTOMER][NEUTRAL] No, how do you, um, how do you pay me by check?
[CUSTOMER][NEUTRAL] Or you do direct deposit.
[AGENT][NEUTRAL] Um, let's see.
[AGENT][POSITIVE] Well, I'm showing that you're set up on direct deposit, so it'll be direct deposited.
[CUSTOMER][NEUTRAL] Oh great OK alright and that would be in the payment preferences, right?
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][POSITIVE] Yeah, the information is, yeah, I just looked at it. The information is still accurate. OK, perfect.
[AGENT][NEUTRAL] OK. And is there anything else that I can assist you with, [PII]?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] No, that was it. That's all I needed to confirm how to take care of the problem.
[AGENT][POSITIVE] OK. Well, I thank you again for calling APL. You have a great rest of your day.
[CUSTOMER][POSITIVE] You too. Thank you very much for your assistance. I appreciate it and your patience. Thank you.
[AGENT][POSITIVE] Oh, no problem. Thank you. Mhm. You're welcome. Mm bye.
[CUSTOMER][NEUTRAL] All right bye bye uh huh bye.