AccountId: 011433970860
ContactId: 3725b869-db14-4167-b012-0148f93e7814
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1293630 ms
Total Talk Time (AGENT): 441297 ms
Total Talk Time (CUSTOMER): 675741 ms
Interruptions: 4
Overall Sentiment: AGENT=0.9, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/16/3725b869-db14-4167-b012-0148f93e7814_20250116T21:36_UTC.wav
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[AGENT][NEUTRAL] Hi, thank you for calling APL. This is [PII]. How can I help you today?
[CUSTOMER][NEUTRAL] [PII], this is [PII]. I've had a claim out since July of last year.
[CUSTOMER][NEGATIVE] And I'm still not getting any satisfaction of one way or the other. I did submit my.
[CUSTOMER][NEUTRAL] Bills or whatever to you.
[CUSTOMER][NEUTRAL] And uh my claim number is 354.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 5992.
[AGENT][NEUTRAL] OK, let me look that up for you, [PII].
[AGENT][NEUTRAL] And [PII], would you be able to verify for me, please, your first and last name and date of birth?
[CUSTOMER][NEUTRAL] [PII], that's [PII]
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] My date of birth.
[AGENT][POSITIVE] Perfect.
[CUSTOMER][NEUTRAL] You want my address?
[AGENT][NEUTRAL] Yeah, I will need your address if you don't mind.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Perfect and then the only other thing if you could verify for me it's your mailing address or your I'm so sorry, I just said that your email address.
[AGENT][POSITIVE] Goodness.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Perfect, thank you.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Let's see what we're looking at here. Alright, I do see that claim on file.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Now one this whole plan supposedly now I guess started [PII] of last year.
[CUSTOMER][NEUTRAL] And I thought I had you guys since [PII], but.
[AGENT][NEUTRAL] Yes, I do have that.
[CUSTOMER][NEUTRAL] The claim is for [PII], and [PII], 3 emergency room visits in one week.
[AGENT][NEUTRAL] OK, so I do see those here, but I'm not seeing where we received any further information um on the policy that was submitted to us.
[CUSTOMER][NEUTRAL] Did you
[CUSTOMER][NEUTRAL] Did you, I sent the whole paperwork from the health system to you guys. I mailed it.
[CUSTOMER][NEUTRAL] And it was talking about the 3 visits.
[CUSTOMER][NEUTRAL] The ERs, the doctors, what they did.
[CUSTOMER][NEUTRAL] I don't know what more.
[CUSTOMER][NEUTRAL] Can you deal with the, the hospital?
[AGENT][NEUTRAL] You know, I don't believe we do reach out to the hospital. No, I'm sorry, but I can double check with you, I can double check on that for you. Um, I do see that they did request um itemized statements of the services providing, including diagnosis codes for services rendered the [PII], and then again, there was one on [PII].
[AGENT][NEUTRAL] Um, and so they were wanting the itemized statements with your diagnosis codes on all of those and.
[CUSTOMER][NEUTRAL] That's what I sent you
[AGENT][NEGATIVE] But I'm seeing we we don't, I don't show it was ever received.
[CUSTOMER][NEGATIVE] And see I don't even have it anymore.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] You want me to read the letter that I just received? Probably doesn't make any difference.
[AGENT][NEUTRAL] Yeah, what did you just receive?
[CUSTOMER][NEUTRAL] This is from uh M Health Fairview, the, the facility that I went to for the, the emergency visits at M Health Fairview, we are committed to providing high quality and compassionate care for every patient we are vileged to care for. We apologize for your experience was not positive.
[CUSTOMER][NEUTRAL] Thank you for contacting Patient Relations, [PII] regarding your emergency department visits [PII], and [PII] at ML Fairview Northland Medical Center during your conversations, you mentioned, you sought multiple visits to an emergency department where you were discharged despite significant health concerns. It was later revealed.
[CUSTOMER][NEUTRAL] Uh, that you had fractured ribs. That wasn't revealed to me till the [PII].
[CUSTOMER][NEUTRAL] Leading to feeling uncertainty about the care you receive. Given the number of visits and the delayed diagnosis, you feel that you should not be held responsible for the charges associated with these encounters. As the initial evaluations did not adequately address or identify the underlying issue, which was the broken ribs.
[CUSTOMER][NEUTRAL] Your concerns were relayed to the attaining providers, site medical director of emergency services, and vice president of Medical Affairs for review.
[CUSTOMER][NEUTRAL] That review has now been completed. Medical leadership conducted a thorough review of your case and confirmed that the care provided by the attending providers was appropriate. On [PII], the attending provider obtained a CT scan of the chest that did not show any fractures of the ribs. However, there was a gap of more than an inch of cartilage between the actual rib bones and the breast bone.
[CUSTOMER][NEUTRAL] In the middle of your chest, this gap is necessary to allow the chest to expand and contract with breathing. With these results, it was not possible to make the diagnosis. On [PII], the attending provider shared a greater concern by developing secondary by a concern of developing secondary pneumonia and the chest X-ray.
[CUSTOMER][NEUTRAL] Uh, was with rib details was obtained to rule out pneumonia. The results of your X-ray were negative for any fractures.
[CUSTOMER][NEUTRAL] On [PII], your persistent pain and repeat seat.
[CUSTOMER][NEUTRAL] Uh, repeat CT was obtained with results of a fracture.
[CUSTOMER][POSITIVE] Of your cartilage. This visit and the CT did provide a better explanation of the cause of your pain. Medical leadership shares that X-rays cannot always show fractures, but treatment of your care along with confirmation of a fracture remained the same. Medical leadership assures you that all of your concerns during each visit were taken seriously and addressed properly.
[CUSTOMER][POSITIVE] Appropriately
[CUSTOMER][POSITIVE] Thank you, [PII]. We understand that medical encounters can be stressful. We are sorry that these encounters did not meet your expectations. We appreciate the opportunity to review your concerns, as it not only allows us to address the specific issues, but also helps us improve the overall experience for our patients and their families.
[CUSTOMER][NEUTRAL] At this time your insurance has not processed your emergency department encounters. Please reach out and contact information below when those claims have been processed so potential adjustments can be considered at that time. If you have any questions or remaining concerns, please call me at.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]. Sincerely, Maha, patient relations liaison.
[CUSTOMER][NEUTRAL] Minnesota M Health Fairview Lakes and Northlands Hospital.
[CUSTOMER][NEUTRAL] That's a complete letter.
[CUSTOMER][NEUTRAL] No, I submitted.
[CUSTOMER][NEUTRAL] A letter to the gun.
[CUSTOMER][NEUTRAL] I think it was a gun address uh.
[CUSTOMER][NEUTRAL] Let me see NovaCare, Innovacare.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII] and that's where I submitted my paperwork to.
[CUSTOMER][NEGATIVE] And that was sometime in, I think December because it was late and delayed and I figured the insurance was handling it and then finally started getting information from M Health Fairview that nothing has been paid or nothing's been taken care of and I'm stuck with the bill.
[AGENT][NEUTRAL] OK, um,
[CUSTOMER][NEUTRAL] After paying insurance [PII].
[AGENT][NEUTRAL] And you said you mailed that information to [PII]. Do you know who you mailed it to?
[CUSTOMER][NEUTRAL] In NovaCare
[AGENT][NEUTRAL] Novacare, OK. So Novacare doesn't communicate with us, so.
[CUSTOMER][NEUTRAL] It says submit
[AGENT][NEUTRAL] So they definitely
[CUSTOMER][NEUTRAL] Well this is my
[CUSTOMER][NEGATIVE] This is my PHCS card, and when you go to the back of it, it says submit claims to EnovaCare.
[CUSTOMER][NEUTRAL] So that's where I sent it, but now you guys APL has submitted me the charges submitted are not payable because services were rendered prior to the policy's effective date. Well, that was for some stuff I had done in May, but then the July ones in order to complete the process in your claim, we need itemized statements of services provided listing.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The diagnosis codes that I sent to Enovacare.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so we needed that sent to us because we don't communicate with NovaCare.
[CUSTOMER][POSITIVE] And you have got that much.
[AGENT][NEUTRAL] Um, we, we're out of [PII].
[CUSTOMER][NEUTRAL] How did I get this from ATL?
[CUSTOMER][NEGATIVE] How did I get this? What I'm reading to you now, the charges submitted are not payable and then the other one in order to complete the processing your claims need, so you guys have been notified of this because you're responding to it with this letter that I got from you.
[AGENT][NEUTRAL] OK, yeah, I see that we received a claim.
[AGENT][NEUTRAL] From like filled out by you with one of our claim forms.
[CUSTOMER][NEUTRAL] Must have been, yeah.
[AGENT][NEUTRAL] But you didn't submit this claim to us?
[CUSTOMER][NEUTRAL] I'm pretty sure I did.
[AGENT][NEUTRAL] Yeah, it looks like you received your original claim.
[CUSTOMER][NEUTRAL] But now
[AGENT][NEUTRAL] Let me go.
[AGENT][NEUTRAL] Back to that page.
[AGENT][NEUTRAL] I mean, I see your original payment on here that we we received back in.
[AGENT][NEUTRAL] December that has
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] 92
[AGENT][NEUTRAL] But it's the only communication I show we received from you and I re I mean I see that we received like a like the information on your visits and I see that they you have the procedure codes and the um charges and so that is part of like what we need but we need paperwork with the diagnosis code and it looks like we never received any follow up paperwork that has the diagnosis code on it.
[CUSTOMER][NEUTRAL] With broken ribs.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Yeah, and so we have to have that code though um like it's a medical code we have to have to process claims and I can let you know the name of a form.
[CUSTOMER][NEUTRAL] Even that letter I just spread to you.
[CUSTOMER][NEUTRAL] Can you contact?
[CUSTOMER][NEUTRAL] Can you contact that [PII] at the the number the patient relations through email Fairview that I gave you?
[CUSTOMER][NEUTRAL] She's got a phone number here and everything?
[CUSTOMER][NEUTRAL] And this is uh the same policy number?
[CUSTOMER][NEUTRAL] That I gave to her is on this APL form.
[CUSTOMER][NEUTRAL] 0502504490
[CUSTOMER][NEUTRAL] And it's the claim number of the 354-599-2.
[AGENT][NEUTRAL] OK, yeah, let me, um, follow up. I don't know if we can reach out and ask for your um your medical information, uh, with, so first off, I'm not, I'm not sure if we can do that at all, but even if we could do that, I'm pretty sure we would need a release form filled out on our behalf stating that we can even ask for medical information. So I'm just going to see if that is something that we can possibly even.
[AGENT][NEUTRAL] Um, do for you, OK?
[CUSTOMER][NEUTRAL] Wait a second now, is, um, is this an insurance company?
[AGENT][NEUTRAL] Uh, yes, we are an insurance company.
[CUSTOMER][NEUTRAL] It's not a group share plan or anything like that, is it?
[AGENT][NEUTRAL] No, we're an insurance company.
[CUSTOMER][NEGATIVE] I don't understand why in Health Carey didn't submit this to you themselves.
[AGENT][NEGATIVE] I don't know either. No, they should have that would have been really nice because then they could have just sent us all the information and.
[AGENT][NEUTRAL] We, you know what I mean? Like that would have been really convenient.
[CUSTOMER][NEUTRAL] Maybe I'm just.
[CUSTOMER][NEUTRAL] Maybe I'm just gonna go on.
[CUSTOMER][NEUTRAL] Because you tell me that in Health Fairview is part of your organization or uh what benefit of providers or something.
[AGENT][NEUTRAL] Well, we work with any provider, um, so this is a supplemental policy we're not limited to a network we can work with any provider, um, so long as they submit us a claim form.
[CUSTOMER][NEUTRAL] Group of
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Well then I'm gonna go down there right to the hospital and.
[CUSTOMER][NEUTRAL] If there's an office for fun there or checking in and I'm gonna go and give them this card again so they put that on my plan.
[AGENT][NEUTRAL] Yeah, ask them to submit a claim.
[AGENT][POSITIVE] Perfect, yeah, and ask them to send us a claim for those dates of service so we can reconsider them for you, um, and typically it's the first time they send it they they typically know all the information we need.
[CUSTOMER][NEGATIVE] I don't understand
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] And now then again this is PHCS correct?
[AGENT][NEUTRAL] I don't know what PHCS is, no, I'm sorry.
[CUSTOMER][NEGATIVE] That's what I'm getting confused about how I needed it.
[AGENT][NEUTRAL] We're American public life.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] And I'm getting letters back from you saying this and.
[CUSTOMER][NEGATIVE] And you're not associated with this in no care in any way.
[AGENT][NEUTRAL] So you're um you're with Business Workers of America and what they do is they string together um different providers to provide you a comprehensive set of benefits and we are only one part of it so we don't work with we work with Business Workers of America and Business Workers of America works with probably your NovaCare and your multiplan.
[CUSTOMER][NEUTRAL] BWA
[AGENT][NEUTRAL] And those other avenues, but we're just independent so we don't communicate to those other areas. Does that make sense?
[AGENT][NEUTRAL] I'm sure it's confusing.
[CUSTOMER][NEUTRAL] Start to figure it out a little bit, but now you have me as a member number.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] On the 682.
[CUSTOMER][NEUTRAL] 567453
[AGENT][NEUTRAL] I actually, your policy number with American Public Life is 2,504,490.
[CUSTOMER][NEUTRAL] And that's what I have also.
[AGENT][POSITIVE] Yes, so that's your one for us.
[CUSTOMER][NEUTRAL] I don't
[AGENT][NEUTRAL] That other one might be your multiplan or PH I just had to Google it, but it's multiplan is the same thing um the PHCS.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] But APO would handle my medical stuff also.
[AGENT][NEUTRAL] Yes, so what you have with us is a limited hospital indemnity policy, and so we can help provide benefits um based off that policy.
[CUSTOMER][NEUTRAL] I don't know how
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I called one of these outfits associated with the medical cards that I've received today or that I've been carrying in my wallet.
[CUSTOMER][NEUTRAL] And they had no idea of nothing neither. I think that was a Strata Health group. Have you ever heard of Strata Health Group?
[AGENT][NEUTRAL] No, I haven't.
[CUSTOMER][NEGATIVE] That's who my money is being taken from.
[CUSTOMER][NEUTRAL] Like on the [PII] of every month.
[CUSTOMER][NEGATIVE] For the since the [PII] and now I've talked to them and then somehow or another they keep pushing me back to you guys.
[AGENT][NEUTRAL] I'm so sorry. I definitely sounds really confusing. It seems like there's a lot of.
[CUSTOMER][NEUTRAL] It
[AGENT][NEUTRAL] Different things at play and I wish I like knew.
[AGENT][POSITIVE] You know what I mean, I wish I could see how they all interacted with each other so I could help you navigate it.
[CUSTOMER][NEUTRAL] That's
[CUSTOMER][NEUTRAL] Right, that's 8 months now times $356 a month.
[CUSTOMER][NEGATIVE] And I've got, I can't even get phone numbers to talk to people that understand what's going on, but yet you have me on file.
[AGENT][POSITIVE] Yes, I definitely have you on file, um.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEGATIVE] That's the confusing part.
[AGENT][NEUTRAL] I'm really
[AGENT][NEGATIVE] Sorry that, that it's been so confusing. Um, I wish, I wish it had been simpler for you and honestly, I really wish the hospital had just sent their claim to us and
[AGENT][NEUTRAL] You know it didn't make you jump through all these hoops sending in all these different paperwork so um.
[CUSTOMER][NEUTRAL] I'm gonna get to the hospital right now and I'm gonna see if I can get him and I'm gonna take this APL letter.
[CUSTOMER][NEUTRAL] Because this is who I'm talking to now it's through a.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] And see if they can't get this going straight again.
[AGENT][NEUTRAL] And if they give you a hard time, if it seems like they're not gonna um help you submit a claim or like submit a claim on your behalf um I have a form that you can ask for for them um if you have like a pen and paper and can write down the name of the form and that will be if you can get that form for the service states on our side um that will be all the paperwork we need to reconsider on your claim.
[CUSTOMER][NEUTRAL] Where is this form coming from you?
[AGENT][NEUTRAL] Um, from the hospital. We need it from the hospital, but it's a UB04 is the name of the form, and that will have your diagnosis code.
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] U as in umbrella, B as in boy.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 04.
[CUSTOMER][NEUTRAL] What else
[CUSTOMER][NEUTRAL] 04
[AGENT][NEUTRAL] Mhm and that's um the UB 04 form will have the diagnosis code which is all we're missing on those dates of service um for July and the one in.
[AGENT][NEUTRAL] The one in October and so if you can get that form for those dates of service um and if they ideally if they can do it let them do it because they'll make your life easier but if they seem to be giving you a hard time and they don't want to submit the claim or whatever they say um at least try to get that form from them for those dates and and then I'd recommend like faxing us that and letting us go from there because it looks like we just need.
[AGENT][NEUTRAL] Something with your diagnosis code and that will have it.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] It's my pleasure. I'm sorry everything's so rough right now for you, [PII], but I really want to do my best to take care of you and I appreciate your patience and what seems like an ongoing endeavor.
[CUSTOMER][POSITIVE] I like I, I even talked to the hospital about 2 weeks ago and I said, I'd rather be giving them $356 a month and not have to worry about health coverage at all, you know.
[AGENT][POSITIVE] Oh my gosh. That'd be a kind of a fun way to do it.
[CUSTOMER][NEUTRAL] Because for these two is just crazy.
[CUSTOMER][POSITIVE] But thank you.
[AGENT][POSITIVE] Yes, it's my pleasure thank you so much and if you need any help along the way just give us a call OK?
[CUSTOMER][POSITIVE] I will thank you.
[AGENT][POSITIVE] Thank you. My pleasure. Bye bye.
[CUSTOMER][NEUTRAL] Bye bye.