AccountId: 011433970860
ContactId: 4418d5bb-5fcc-4988-9678-b272364bdbbb
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1193510 ms
Total Talk Time (AGENT): 477077 ms
Total Talk Time (CUSTOMER): 290734 ms
Interruptions: 2
Overall Sentiment: AGENT=0.1, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/30/4418d5bb-5fcc-4988-9678-b272364bdbbb_20250430T17:33_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]. This is [PII]. I was just talking to someone I got cut off.
[AGENT][NEUTRAL] Oh, I'm sorry, [PII], uh, what's going on?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK. So I put 2 claims in the APL. I was telling her. My husband, he was having surgery, but his cardiologist wanted him to have a stress test.
[CUSTOMER][NEUTRAL] So because it was so, it was like so fast, he went in. They admitted him into the hospital at [PII] for the stress test.
[CUSTOMER][NEUTRAL] And then he got out on the [PII], but then went back in on the [PII] for the actual surgery.
[CUSTOMER][NEUTRAL] Um, so I, I submitted everything and it looks like you only paid one claim.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Not both.
[AGENT][NEUTRAL] OK, alright, yeah, let's look at it. Do we have claim number, policy number? What do we have?
[CUSTOMER][NEUTRAL] I have a policy number.
[AGENT][POSITIVE] Perfect. OK. What's that?
[CUSTOMER][NEUTRAL] 204.
[CUSTOMER][NEUTRAL] 1957
[AGENT][NEUTRAL] OK, and then [PII] just in case if anything happens on the call, uh, what is a good callback number?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] All right, perfect.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right, I've got the policy pulled up. I do need to verify for security, please, the date of birth and then address.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mine
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Oh, OK. [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And the address is [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you. OK.
[AGENT][NEUTRAL] So last claim for [PII] was submitted 424, processed 425.
[AGENT][NEUTRAL] And that one paid.
[AGENT][NEUTRAL] Let me look at the one before that one.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so it's
[CUSTOMER][NEGATIVE] I'm so confused because
[AGENT][NEUTRAL] So it shows inpatient there was a claim inpatient 115 to 117.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And then there was an inpatient 115, 125.
[CUSTOMER][POSITIVE] Well, see, they keep combining that second one.
[CUSTOMER][NEUTRAL] Because he left and then he came back.
[AGENT][NEUTRAL] Well there are two separate lines so it's one for 115 through 117 and then a charge amount and then there's a separate line for 115 through 125 for a separate charge amount.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So, on this particular claim, it was denied, it's just needing the explanation of benefits from your primary insurance. We need to see what the
[CUSTOMER][NEUTRAL] Which I did.
[AGENT][NEUTRAL] OK. Let me check that.
[AGENT][NEUTRAL] Because we need to see what they paid.
[CUSTOMER][NEUTRAL] I think this, I did think I sent all that.
[AGENT][NEUTRAL] I can double check and see um if they missed it or something like that.
[CUSTOMER][NEUTRAL] But I have the forms that I've already downloaded are gone.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] You don't need to res.
[CUSTOMER][NEUTRAL] Isn't this the explanation though like?
[AGENT][NEUTRAL] You don't need to resubmit the forms you would just need to submit or upload the explanation of benefits from your primary, so you wouldn't have to redo everything.
[CUSTOMER][NEUTRAL] OK, but this, OK, so this is.
[CUSTOMER][NEUTRAL] That's what I'm looking at.
[CUSTOMER][NEUTRAL] Can I move this now.
[CUSTOMER][NEUTRAL] is one
[CUSTOMER][NEUTRAL] Admission date [PII].
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Admission date [PII].
[CUSTOMER][NEUTRAL] So it's there it's under that file.
[CUSTOMER][NEUTRAL] Where did I find these?
[CUSTOMER][NEUTRAL] I found these under
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Claim number 359-31997.
[AGENT][NEUTRAL] OK, so this is an itemized bill from the hospital.
[CUSTOMER][NEUTRAL] Ok, so are you.
[CUSTOMER][NEUTRAL] I think that's what I got let me look at this.
[CUSTOMER][NEUTRAL] Hold on, let me look and see what this looks like.
[AGENT][NEUTRAL] So is United Health, is United Health Care your primary?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, so what we need is from United Healthcare. We need to see an explanation of benefits from United Healthcare showing that they paid whatever they paid for this date of service and then what the remaining was. So the document you need is from United Healthcare.
[CUSTOMER][NEUTRAL] OK, and I sent all that in, but it's not there.
[AGENT][NEUTRAL] I don't
[CUSTOMER][NEUTRAL] I don't know what somebody did with a doctor.
[AGENT][NEGATIVE] Yeah, I mean, I don't, unfortunately.
[CUSTOMER][NEUTRAL] Because I did all this.
[AGENT][NEGATIVE] Yeah it, it's just 2 pages uploaded.
[CUSTOMER][NEUTRAL] Oh, that was 1:15. Why did I say 1:15? Hold on.
[CUSTOMER][NEGATIVE] Between, see they're combining them, that's my problem.
[CUSTOMER][NEUTRAL] OK, wait a minute
[CUSTOMER][NEGATIVE] I did smell
[CUSTOMER][NEUTRAL] I have like a whole file.
[CUSTOMER][NEUTRAL] I go down far enough. OK, so this says.
[CUSTOMER][NEUTRAL] What does this one say?
[CUSTOMER][NEUTRAL] Emergency services 115 to 117.
[CUSTOMER][NEUTRAL] Laboratory
[CUSTOMER][NEGATIVE] Yeah, I could have what I, I submitted all this 350, but it's not, neither one of them are there.
[AGENT][NEUTRAL] Yeah, I don't see them on my side. I mean, I pulled both of the I pulled the uploads to see the documents that we have on our side. We have the billing um from the facility, the hospital, but I don't show anything for United Healthcare.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Isn't that weird?
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK, if I upload it right now, are you able to see it?
[AGENT][NEUTRAL] Um, we can check if it'll come to, and I'm not sure if it'll come through immediately. It may take a few moments, but you can try it, yeah, and, uh, like I said, you just need to upload the, the explanation of benefits from United Healthcare. That's the only thing that is needed on that.
[CUSTOMER][NEUTRAL] OK, I just uploaded it.
[AGENT][NEUTRAL] Yeah, it doesn't show anything yet.
[AGENT][NEUTRAL] Let me go back out and back in and check again here.
[AGENT][NEUTRAL] OK, so I see a reported upload, but I'm not gonna be able to pull it yet it's not gonna pull up for me yet.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Do you handle the claims?
[AGENT][NEUTRAL] I'm not a claims examiner, no, mm mm.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK, it's just so hard to talk to someone to say, OK, listen, this is what I'm doing and to get it relayed back to the person.
[CUSTOMER][NEUTRAL] That's actually doing the reviewing the claim, you know what I'm saying?
[AGENT][NEUTRAL] Um, yeah, no, absolutely. I mean, they would know that that information was in reference to the denied claim previous to that, that that goes with that. Um, I'm happy to notate the account, our conversation in regards to the claim and then you uploaded the explanation of benefits.
[AGENT][NEUTRAL] It's not out of the normal for a secondary policy for that to be a missing piece of information. Most people that are doing the claims themselves as an insured, unless you're familiar with it, don't know that we need that. Um, most of the time, you know, if a providers doing it on your behalf, they know secondary needs that, so they'll submit it.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So it's not a crazy situation or out of the norm. You can always request to speak to somebody in claims, um, or have somebody in claims call you back if you want to talk to an examiner.
[CUSTOMER][NEUTRAL] I don't know. I, I, what gets me is that I, I know I've already done this because it's in my folder.
[CUSTOMER][NEUTRAL] That I mean I have a folder of the bills, the paid bills, the everything, because I didn't wanna, it was so much going on.
[CUSTOMER][NEUTRAL] That I didn't want to not pay anybody or have it for a claim, and I already have it in my folder. So, I, I know I uploaded both of them, but half the forms that I've uploaded are not there.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I mean, I uploaded so much stuff.
[CUSTOMER][NEUTRAL] But they're not, they're not there for some reason.
[AGENT][NEUTRAL] Yeah, I mean, on this particular
[CUSTOMER][NEUTRAL] But I don't know what.
[AGENT][NEGATIVE] On this particular one, you know, I, the one that was denied, I, you know, I can't answer unfortunately why it didn't show or carry over because I was able to pull the upload and like I said, I saw two pages on the first one,
[AGENT][NEUTRAL] You know, because if there's an error on our part and we see an explanation of benefits, I mean we definitely would then forward that back to the examiner and say, hey, that document is there can you reassess this but.
[AGENT][NEUTRAL] For whatever reason, it
[CUSTOMER][NEUTRAL] Yeah, it is there. I, I.
[CUSTOMER][NEUTRAL] Hospitals, no, that's not it. I, I see it. I, I just viewed it, actually.
[AGENT][NEUTRAL] OK. I mean if you wanna call and double check on it later today or tomorrow just to make sure, you know, once we can pull the download, you're more than welcome to do that um like I said, you're always, you can always request to speak to somebody in claims or have somebody in claims call you as well.
[CUSTOMER][NEUTRAL] OK. If you look, just one thing, if you look under the claim that they paid.
[CUSTOMER][NEUTRAL] Where it says view files.
[CUSTOMER][NEUTRAL] It's in there too.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] It's in that file.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I, I am able to see it?
[AGENT][NEUTRAL] I'm pulling it up. It's 1325 pages actually, so give me just a sec here.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][POSITIVE] That's right. That's alright. I submitted it again. We'll see what happens.
[AGENT][NEUTRAL] OK, so did you get an you probably haven't gotten an explanation of benefits on the paid claim since it was just done, or have you gotten one yet?
[CUSTOMER][NEUTRAL] I have not.
[AGENT][NEUTRAL] OK, so on the paid claim.
[AGENT][NEUTRAL] That was processed.
[AGENT][NEUTRAL] The stay inpatient from 1:15 to 117.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Paid $350.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, inpatient 115 to 125 on this claim.
[AGENT][NEUTRAL] This is the one that paid.
[AGENT][NEUTRAL] It paid
[AGENT][NEUTRAL] $1,058.16 towards that portion of the stay.
[CUSTOMER][NEUTRAL] I'm confused. Why are you combining the dates though? Because there were two separate dates.
[AGENT][NEUTRAL] Well, there are different payments for each state.
[CUSTOMER][NEUTRAL] Uh, he was with.
[CUSTOMER][NEGATIVE] How come I didn't get my maximum on the 2nd day?
[AGENT][NEUTRAL] So it looks like with this payment of this claim, the maximum inpatient hospital benefit has been met for confinement. So that's why that was the max benefit paid between the two.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] But they are separating the two.
[CUSTOMER][NEUTRAL] states.
[AGENT][NEUTRAL] Yes, because the one benefit amount was 350, and that was simply just for 115 to 117.
[AGENT][NEUTRAL] And then the second pay for the 1,05816 is for the 115 through 125, so I can email you this EOB so you can look at it because it's gonna break it down.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And give you payment line by line and then it's also gonna give you any denials and it will show you that on the 1,05816 that that was the max benefit payable for that date of service.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, what is a good email to send it to?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, send it to.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] [PII]?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, [PII].
[CUSTOMER][NEUTRAL] [PII] an [PII]
[AGENT][NEUTRAL] OK. Uh-huh. [PII]. Mhm.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, um, explanation of benefits is on its way to you, so that's gonna break down like I said, it gives you each line item it'll give you the from and to dates. It'll tell you who the provider was, it'll tell you the procedures and the full amount billed, full amount paid, and then why. And then if you go down to page 2.
[AGENT][NEUTRAL] It'll show you any denials and reasons.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So that should hopefully
[CUSTOMER][POSITIVE] OK, thank you very much.
[AGENT][POSITIVE] Yeah, that should clarify hopefully and then if you have any other questions or concerns, [PII], please feel free to call us. Like I said, you can always ask to speak to a claims examiner regarding it if you think that something was incorrect, please don't hesitate to give us a call, OK?
[CUSTOMER][NEUTRAL] Help
[CUSTOMER][POSITIVE] OK, thank you very much.
[AGENT][POSITIVE] You're welcome. Have a nice day.
[CUSTOMER][NEUTRAL] Bye bye.