AccountId: 011433970860
ContactId: 4fea8d29-1f8e-461f-8a45-da80c5496c11
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 716130 ms
Total Talk Time (AGENT): 301313 ms
Total Talk Time (CUSTOMER): 259308 ms
Interruptions: 1
Overall Sentiment: AGENT=0.2, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/14/4fea8d29-1f8e-461f-8a45-da80c5496c11_20250214T15:02_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEGATIVE] Um, yes, ma'am, I'm calling because, um, I, I no longer have this insurance, but when I did have it, there were some claims filed for my son which was a covered beneficiary on my policy, and I'm getting denial saying that um, he, that he wasn't on my policy.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, so is there any way you can check for me?
[AGENT][NEUTRAL] I can check it for you. What's your name?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII], what's the policy number?
[CUSTOMER][NEUTRAL] D 433
[CUSTOMER][NEUTRAL] 02180
[AGENT][NEUTRAL] Were the claims processed by American Public Life?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, so our policy number is different. Do you have your ID card?
[CUSTOMER][NEUTRAL] I do.
[AGENT][NEUTRAL] It's did you see a policy cert number on there that begins with a 0?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Hang on, I'm looking.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Hang on, maybe do I not need the card that says Oxford on it?
[AGENT][NEUTRAL] Is Oxford your employer?
[CUSTOMER][NEUTRAL] Yes, it was.
[AGENT][NEUTRAL] Yeah, so that's the, that's the ID card. Spell your last.
[CUSTOMER][NEUTRAL] OK. OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I, I, it's um 025.
[CUSTOMER][NEUTRAL] 16513
[AGENT][NEUTRAL] OK, is it, is that that number at the bottom of that card?
[CUSTOMER][NEUTRAL] Uh, it says policy er number it's right below where it says my name and then family coverage. It's right below that.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and what's a good phone number, [PII], in case we're disconnected?
[CUSTOMER][NEUTRAL] Um, my number is [PII], but that said dental code bottom of that card.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Hang on, I'm trying to find a.
[AGENT][NEUTRAL] I can locate it with the policy number that you gave me.
[CUSTOMER][NEUTRAL] Here's a, here's
[CUSTOMER][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] Let me see, yeah, that is the dental so this claim is a medical claim that you're calling about?
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] OK, so the medical policy number is 251.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] 6509.
[CUSTOMER][NEUTRAL] 251-650-9
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, I just found an an EOB that had been um.
[CUSTOMER][NEUTRAL] Sent on one of the claims for him.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] And is there a policy number on that document that you're talking about?
[CUSTOMER][NEUTRAL] Uh yes ma'am, it's the same one that you just gave me the 251-650-9.
[AGENT][NEUTRAL] I'm sorry, I'm in a claim number. Did you receive a document?
[CUSTOMER][NEUTRAL] 00
[AGENT][NEUTRAL] From us the EOB, the explanation of benefits.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yes, it's 355.
[CUSTOMER][NEUTRAL] 8248
[AGENT][NEUTRAL] OK. Verify your date of birth and your mailing address, [PII].
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][NEUTRAL] And your email address on file?
[CUSTOMER][NEUTRAL] Um, it should be [PII].
[AGENT][NEUTRAL] OK, thank you and which dependent is it for?
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] It's for [PII].
[AGENT][NEUTRAL] [PII], what's his date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, so let me pull up his information and go to claim 3558248. OK, so that one denied as a duplicate, which means we received it and processed it before, so let me locate the initial one.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] There there may be several claims on him um because I've yeah I've received um.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Several EOBs said it was a duplicate claim, so I just thought it was being taken care of.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Yeah, that just means that the provider sent it to us more than once, so that's all that is. So I'm looking at the original one that was processed on [PII], and it is Pop Pop Poplar Bluff Regional Medical Center.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] OK.
[AGENT][NEGATIVE] So I'm looking at the remark code on the explanation of benefits and it's basically saying that this policy covers 3 diagnostic tests, which would be an MRI, a CT scan, and a colonoscopy. So was the test that he had done, either of those 3, if not, it, it denied as not covered.
[CUSTOMER][NEUTRAL] OK, but the, the reason um I was trying to find.
[CUSTOMER][NEGATIVE] The one for the office visit that's been denied um.
[AGENT][NEUTRAL] OK, let me see. For the same day?
[CUSTOMER][POSITIVE] It it's the benefit.
[CUSTOMER][NEUTRAL] Um, I'm trying to look and see what day it was, um, hang on just a second.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Sorry, I've gotta log in real quick um.
[AGENT][POSITIVE] You're OK.
[AGENT][NEUTRAL] Is it the one that was related to the, well, it's related to an accident. I see that.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK, yes, it was with um.
[CUSTOMER][NEUTRAL] It was with [PII] for [PII] and I'm being billed $180 so he had a secondary insurance at that time, but my secondary one because they said that um 90 degree benefits has not pro hasn't denied the claim or anything because they're saying that that.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] They can't identify him as a covered beneficiary.
[CUSTOMER][NEUTRAL] Is the is the reason that that the doctor's office is being given.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] So your medical and your accident claims are processed through Ame[PII] public life and not 90 degrees.
[CUSTOMER][NEUTRAL] OK, so uh he fell whenever he fractured his wrist.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] So does that mean that that that's not covered for even for the doctor's visits?
[AGENT][NEUTRAL] Yeah, so what I'm doing now I'm looking under the group accident policy that you have to see if it was processed under this policy number.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And let's see.
[AGENT][NEUTRAL] OK, so.
[AGENT][NEUTRAL] I don't see the office visit charge under the accident policy. What I do see is an X-ray.
[AGENT][NEGATIVE] And the X-ray denied, it's saying that X-rays are not covered under this accident policy.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] Give me one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So what I would do is submit that claim that you're talking about under the accident policy and that number it's a different policy number it's 251.
[AGENT][NEUTRAL] 6510.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So whenever they, when
[CUSTOMER][NEGATIVE] I don't know how what I'm trying to ask, so they don't need to put my insurance as 90 degree benefits for this. They do they need to put it under APL then or?
[AGENT][NEUTRAL] Yes, and that's probably where the confusion is, that is correct. So and then they also have to submit it under the correct policy. So since you do have an accident policy, um, you would give them the policy number 251-6510. Ask them to submit that under the accident policy.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, I will ask them to do that um.
[CUSTOMER][NEUTRAL] And is there any way you could check on something else for me for my husband while I have you on the phone?
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] OK, um, his date of birth is [PII] or not [PII], that's mine. I'm sorry, [PII].
[AGENT][NEUTRAL] OK, I have it pulled up here. Is it [PII]?
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][POSITIVE] OK. And how can I help with this one?
[CUSTOMER][NEUTRAL] Um, so he was seen in the ER, um, for chest pains. I'm not sure. I can't remember, maybe on [PII] might have actually been the day before his birthday, um, and they had his insurance all jacked up whenever they put it in, uh, somebody reached out to me to try to get the insurance fixed, but I haven't heard anything.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Back on any of that, can you tell me, has that been processed yet or was it processed correctly? Is there something that I could do to.
[CUSTOMER][NEUTRAL] If it wasn't, is there something I could do to to get it taken care of so that way I won't wind up the bill.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Right, yeah, I do see a claim. Um, it was the emergency room visit. I'm showing it was [PII], and we received a claim from the ER physician's office. We paid them $75. Um, that payment was made to them on [PII], and then we received another claim and processed it on the [PII] of this year and this claim is from Poplar Bluff Regional Medical.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, we issued them a check, looked like he had a CT scan, a $250 check for the CT scan, and the, let me see, emergency room, the facility charge for the emergency room.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Yeah, the maximum is $75 and it was paid to the ER physician.
[AGENT][NEUTRAL] And so for the facility bill regarding the emergency room charge, it didn't cover it because it's saying that we had already paid the maximum on another claim which was the ER physician's charge.
[CUSTOMER][NEUTRAL] OK, um, can, can you
[AGENT][NEUTRAL] Mhm, but we did, we did receive the claims and paid something on them.
[CUSTOMER][NEUTRAL] OK, can you tell me how much they sent, how much the bill was they sent for the facility side?
[AGENT][NEUTRAL] I don't see that you would need to reach out to them, let me see.
[CUSTOMER][NEUTRAL] Does it show?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, reach out to the facility for that bill charge amount.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Looks like it could have been about 19,000 maybe, but if they're contracted with multi-plan, you may have received a discount though.
[CUSTOMER][NEUTRAL] All right, I will
[CUSTOMER][NEUTRAL] OK, yeah, they're they're supposed to be contracted with multi plan so.
[AGENT][NEUTRAL] Right.
[CUSTOMER][POSITIVE] OK. All right. Well, I appreciate your help.
[AGENT][POSITIVE] Oh, you're welcome. Anything else I can help with today, [PII]?
[CUSTOMER][NEUTRAL] No ma'am, that's it.
[AGENT][POSITIVE] OK, thanks for calling APL have a good day.
[CUSTOMER][NEUTRAL] You too bye.
[AGENT][NEUTRAL] Bye-bye.