AccountId: 011433970860
ContactId: 4fb63d1c-ccef-4ed1-a113-8a4bcdabad70
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 680369 ms
Total Talk Time (AGENT): 267696 ms
Total Talk Time (CUSTOMER): 308194 ms
Interruptions: 1
Overall Sentiment: AGENT=0.3, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/12/4fb63d1c-ccef-4ed1-a113-8a4bcdabad70_20250512T20:49_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yes, I'm checking on um a claim that was gonna be reprocessed and um seeing if there's any update on that um I called I called about 10 days ago um I can give you my number or what would you like first?
[AGENT][NEUTRAL] Oh, sure. Do you have your policy number and I can look it up by that.
[CUSTOMER][NEUTRAL] I do 02549425 ML 8.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And what's the claim for yourself?
[CUSTOMER][NEUTRAL] No, for my daughter, um, [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And it was
[AGENT][NEUTRAL] Uh, can you verify your name and date of birth?
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][NEUTRAL] And what is your address?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you. And then do you have a good callback number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yes, [PII].
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And the date of service was from [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And [PII].
[AGENT][NEUTRAL] OK, [PII]. Is that right?
[CUSTOMER][NEUTRAL] Correct. West Kendall Baptist Hospital.
[AGENT][NEUTRAL] OK. Uh, it looks like we processed that and made a payment on [PII].
[AGENT][NEUTRAL] Were you, you had sent something reference to that or is it?
[CUSTOMER][NEUTRAL] He
[CUSTOMER][POSITIVE] Perfect
[CUSTOMER][NEUTRAL] Yes, and that was um so how much is the payment on that?
[AGENT][NEUTRAL] 2,158.
[AGENT][NEUTRAL] 2,158 cents.
[CUSTOMER][POSITIVE] Oh perfect OK.
[CUSTOMER][NEUTRAL] OK, so she's maxed out her um benefits for.
[CUSTOMER][NEUTRAL] Let me think about this for a 2nd, 1 2nd.
[CUSTOMER][NEUTRAL] Um, mm, how does that work?
[CUSTOMER][NEUTRAL] OK, so this, OK, this is the thing our.
[CUSTOMER][NEUTRAL] She was um injured on [PII] and then so that was the last day.
[CUSTOMER][NEUTRAL] Of our
[CUSTOMER][NEUTRAL] Prior benefits. Does that make sense? We started a new plan on [PII], so and so she went into the hospital on [PII] and came out [PII].
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Are her benefits max for
[CUSTOMER][NEUTRAL] From [PII] till now, does that make sense?
[AGENT][NEUTRAL] No, they run on a calendar year, so it's not based on your plan policy calendar, yep.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] OK, so it would be $4000 for [PII], the year of [PII].
[AGENT][NEUTRAL] Correct, yeah. So let me make sure that's your policy amount. Just give me one moment.
[CUSTOMER][POSITIVE] Correct. OK.
[CUSTOMER][NEUTRAL] Cause it was
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] A different policy amount up to 8:31 but then it changed so I'm not sure how that works.
[AGENT][NEUTRAL] OK, yeah, the maximum payout of 4000 per calendar year.
[CUSTOMER][POSITIVE] OK perfect so.
[CUSTOMER][NEUTRAL] So then, so I have a stack of bills that's why and I've been dealing with this for a while but so then since that her um 4000 is maxed out, then I would.
[CUSTOMER][NEUTRAL] Oh, like all the little bills that.
[CUSTOMER][NEUTRAL] Haven't been taken care of, correct?
[AGENT][NEUTRAL] Um, so we wouldn't, yeah, so if we've maxed out her policy, if she's maxed out the 4000, there's nothing left on this policy that would pay anything else.
[CUSTOMER][NEUTRAL] Is that correct? Yes.
[CUSTOMER][NEUTRAL] OK, OK, OK perfect and then um one more question, so do they, uh, and you might not be, you might not know this, but do they normally want APL pays the provider, do they normally send out a um corrected bill?
[AGENT][NEUTRAL] Uh, they send the provider an explanation of benefits, so it'll show, you know, they'll get the, the claim and then, um, our payment and then I don't know if they'll send you a corrected bill if anything's due, um, I would think that they would, but not sure about that we, we just send them an explanation we show how it's paid and then they get the payment and then apply it accordingly.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK perfect um so that was done on [PII], and that was, could you tell me that amount one more time? $2100 and what was there any dollars?
[AGENT][NEUTRAL] Uh 58 cents.
[CUSTOMER][NEUTRAL] $2100.58 correct?
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][POSITIVE] OK, thank you so much for your help I appreciate it.
[AGENT][NEUTRAL] OK. Anything else I can help with, Ms. [PII]?
[CUSTOMER][NEUTRAL] Um, not right at this moment. Um, I do have, well, I, I, my, my other daughter had a bunch of tests done last summer, and so we just now got the very first bill. It was a year ago actually, and, um, so my regular primary insurance has done their part.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEGATIVE] And then there's a still $425 but they did not put our APL information. I've tried to call them. I've emailed them, giving them the information. I've not heard anything. Is there any way you can check and see if they, if they have anything on that bill?
[AGENT][NEUTRAL] Uh, sure, let me see. And who is that for?
[CUSTOMER][NEUTRAL] It's, it's from 31002. It's for [PII]. [PII] it's her birthday and um that was for [PII].
[CUSTOMER][NEUTRAL] Of last year.
[AGENT][NEUTRAL] [PII]. OK.
[CUSTOMER][NEUTRAL] Yeah, I mean that there's actually 3 dates, but.
[CUSTOMER][NEUTRAL] That will probably tell it's all on the same bill so I'm assuming that.
[CUSTOMER][NEUTRAL] If they did that they did all the rebates.
[AGENT][NEUTRAL] OK, let me see.
[AGENT][NEUTRAL] OK, give me one moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] And you said it was from [PII], is that right?
[CUSTOMER][NEUTRAL] Correct, [PII].
[AGENT][NEGATIVE] OK, no, how about we have not received anything.
[CUSTOMER][NEUTRAL] OK. So
[CUSTOMER][NEUTRAL] Besides going to their door, is there any other suggestions as far as trying to get them to um use my secondary insurance, which is you guys?
[AGENT][NEUTRAL] Uh, my only other suggestion, you could, if, if [PII] doesn't have an online account, she can create one with whatever hospital provider that is, and you might be able to gather the information off of their portal, um, because if, I mean, you can get your primary EOB um from your primary insurance, we need that and then we need the claim information. So we need like the date of service, what charges did they bill.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, where was it rendered and then like the diagnosis and procedure codes. Sometimes that can be found on those online portals at the hospitals. So if she created an online account with her information, um, you possibly could pull it from that if you're not getting their cooperation.
[CUSTOMER][NEUTRAL] OK, and there's um would it be possible to send the statement with the.
[CUSTOMER][NEUTRAL] With the like the statement with all that information or no?
[CUSTOMER][NEUTRAL] We need to be more detailed than that.
[AGENT][NEUTRAL] You can. It's just, yeah, we typically, it's a lot of times those statements are pretty vague, so we, we do have to see like what pro what procedures were rendered, you know, was it an X-ray, surgery, etc. and then what was the diagnosis.
[CUSTOMER][NEUTRAL] This
[CUSTOMER][NEUTRAL] Oh, the diagnosis, OK, because this, the procedures and the codes are on this particular statement, but um as far as the diagnosis that I do not know about. OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, and sometimes those are they are actually located on those online portal accounts so um you just obviously need her information, her social and all that good stuff to create one of those so.
[CUSTOMER][NEUTRAL] OK, alright, um, and so when you say portal I'm sorry like you would find that under Sunset Radilogy which is the name of the place, or?
[AGENT][NEUTRAL] Yeah, sunset radiology or was it tied to a hospital, like an ER visit or anything like that?
[CUSTOMER][NEUTRAL] No, it's just a radiology place.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, you could see, you could call them and see, do they have a way for you to log into the account so you can look at the information. Um, uh, sometimes radiology doesn't have that, but I know hospitals do usually and then physician offices, but definitely, it's worth a try at least if they're not gonna give you the claim. Um, another option possibly would be like contacting your primary or your primary insurance. Did you say it's UnitedHealthcare?
[CUSTOMER][NEUTRAL] Aetna.
[AGENT][NEUTRAL] Aetna. OK, sorry, um, so another route could be contacting Aetna, explaining that is there any, now you would have to have authorization to talk to them and get claim information um from Bailey, but so asking them, do they have the claim information they could share with you, um, because they had to have a claim from Sunset Radilogy to pay on that, and that claim has all the information we need too.
[CUSTOMER][NEUTRAL] Aetna, sorry, it's OK.
[CUSTOMER][NEUTRAL] OK
[AGENT][POSITIVE] So that's another potential out.
[CUSTOMER][NEUTRAL] Well, I
[CUSTOMER][NEUTRAL] OK, um, so the EOB and the claim is not the same?
[AGENT][NEUTRAL] No, it's not. The EOBs typically, they're not gonna have diagnoseses on them. They'll just say, sometimes they do show the procedure like X-ray, um or ultrasound or whatever, but they won't have that diagnosis, um, and that's what we need in addition to that procedure, bill charges and where the services were rendered.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So, if, if
[CUSTOMER][NEUTRAL] So you don't think it would be on the EOB or they doesn't know it's not normally.
[AGENT][NEUTRAL] It's not normally. You can check for sure, but um it's not normally listed, so, but definitely check. It's uh yeah.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All right, thank you so much.
[AGENT][POSITIVE] OK, thanks for calling APL. I hope you have a good day.
[CUSTOMER][POSITIVE] Appreciate your help.
[CUSTOMER][NEUTRAL] You as well.