AccountId: 011433970860
ContactId: 586da3bd-bba9-40ec-84c3-0d2fa437213a
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1055530 ms
Total Talk Time (AGENT): 450334 ms
Total Talk Time (CUSTOMER): 315071 ms
Interruptions: 1
Overall Sentiment: AGENT=0.4, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/09/586da3bd-bba9-40ec-84c3-0d2fa437213a_20250109T20:31_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, um, I had filled out a, uh, contact us form online and then I received a call back about my question and then I missed the call.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Did they happen to leave a name or?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And may I have your name and a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Sure, [PII].
[AGENT][NEUTRAL] And Ms. [PII], um, I'm sorry, the contact number.
[CUSTOMER][NEUTRAL] Oh, I'm sorry, [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have your policy number?
[CUSTOMER][NEUTRAL] Sure. It is 247-581-9.
[AGENT][POSITIVE] Thank you. Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] OK, and I have you here. I just need you to verify your date of birth, your mailing and email address on file.
[CUSTOMER][NEUTRAL] Sure, [PII]. My address is [PII]. Um, I'm not sure if you have my work email or my personal email, but it's um [PII] or [PII].
[AGENT][POSITIVE] OK, it was the [PII] and thank you so much for verifying, and she called you today or was it like a few days ago?
[CUSTOMER][NEUTRAL] Today.
[AGENT][NEUTRAL] OK, um, and what questions did you have?
[CUSTOMER][NEUTRAL] So I was wondering if there was a way to go paperless with um I believe their EOBs um where it lists like what you're gonna pay versus um not paying and then also um I get letters about um that you've received a claim and that you're reviewing documents or something and I was just wondering if I could be emailed those instead of mailed.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So that is something that we're working on, but for right now, um, it's not paperless, is not an option, but I'm gonna double check because I believe we can do for the um
[AGENT][NEUTRAL] Like your explanation of benefits. So let me double check on that part. Um, do you mind if I place you on just a brief hold?
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Boom boom.
[AGENT][NEUTRAL] Wait, where's my guru?
[AGENT][NEUTRAL] Oh Lord, I clicked up my guru. Hold on.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Hello, Ms. [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Hey, thank you so much for holding. I apologize for that wait. Um, so yes, paperless for both is not yet an option. Um, now they do have like if you, or we do have, if you, um, like put your cell phone number in the online service center, it'll send you like um confirmation we received it, kind of like the letters that you you received, but you would still receive those letters.
[CUSTOMER][NEUTRAL] OK, but, um, so it'd be letter and text?
[AGENT][NEUTRAL] Yes, ma'am, for now, um, but they are working on the paperless option.
[CUSTOMER][NEUTRAL] OK, I think I'll just hold off on the text then until the paperless option is available. Um, I did have another question. I noticed that um one of the claims uh recently um was labeled um as my spouse instead of my child. They do have the same name, though my son is the 3rd instead of the 2nd, but I didn't know if that matters.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] What um you said it's under your child and not the spouse, let me look at the.
[CUSTOMER][NEUTRAL] Yeah, it's coded, it's coded under my spouse as my spouse's claim instead of my child's claim.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And which, um, do you have a claim number for that? Does it end in 6201 or 619901?
[CUSTOMER][NEUTRAL] Yes, 6201 mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I'm just pulling up the explanation of benefits.
[AGENT][NEUTRAL] I'm just waiting for it to come up. Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then, hold on one moment. OK, so in terms of the claim itself or the check that was received, I just want to make sure on that explanation of benefits like if it's specified 3rd or anything. So for the check purposes, since there's no specification, he'll still be able to uh use the check, but I do see there where you see relationship and it says spouse, that's what you mean?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, we didn't receive a check. I guess that the check goes to the uh the facility or whatever, yeah.
[AGENT][NEUTRAL] It went to the provider.
[AGENT][NEUTRAL] OK, so yes, then, um, as far as the, I can put a note in there just so they pay attention, you know, pay attention next time, um, but as far as the claim, it's OK, um, because it went to the provider.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Oh, OK. I just didn't know if it impacted what was covered or anything like that.
[AGENT][NEUTRAL] Oh, no, ma'am. It doesn't.
[CUSTOMER][NEUTRAL] OK. OK, perfect. And then my other question that um I just can't keep straight is um does my, um, does this insurance cover copays or I'm just so unclear on when it covers things and when it doesn't cause like it covered uh for that claim, which was like a kid's urgent care facility, but like just a standard co-pay, it seems like it doesn't cover that.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so this policy is um second to your Blu[PII] Cross Blue Shield anthem. So anytime you give the anthem card, just go ahead and give ours. Um, we pay towards, so like if [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] There's two things, but if Anthem like applies a copay or something, um, our policy helps pay that co-pay or deductible. If you've already paid it, then on the back end when we receive the claim, you can be reimbursed for that, but that's of covered charges. So let me pull up your, let me get out of this claim. Hold on one second.
[AGENT][NEUTRAL] I'm going to pull up your um policy documents so that I can see what all your coverage is because some of the policies don't have office visit coverage and then in that case,
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That co-pay wouldn't be um reimbursed or covered because it's not covered on this policy, but I'm going to check and make sure.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so for outpatient, you have up to $4000 per calendar year. So the policy itself does not have like office visit coverage. You know how sometimes the provider can build like a bill for the facility and then bill for like the treatment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So if they were to bill for like a place of service or or the location, then there would be no coverage, but you've added the office treatment rider to where any treatment in the office as long as it's not like cosmetic, it could be pro in office procedures, any treatment in the office, um, as long as it's not cosmetic, um, should be covered up to that $4000 per calendar year. So you may see something where
[CUSTOMER][NEUTRAL] But
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] Go ahead, I'm sorry.
[AGENT][NEUTRAL] No, you're fine.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Um, so, like, for instance, um,
[CUSTOMER][NEUTRAL] I went to the gynecologist for an office visit, but the $70 co-pay.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, they said wasn't like APL didn't cover it, is that correct?
[AGENT][NEUTRAL] Um, do you, well, I can look at it. Do you know like when around when you went? I can look for like the data service.
[CUSTOMER][NEUTRAL] Um, it probably.
[CUSTOMER][NEUTRAL] Was in September. Let me see this 3,509,550.
[AGENT][NEUTRAL] September.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Um, let me see if it takes a let me look in Waterford.
[AGENT][NEUTRAL] Oh, take your time. I'm looking through the claims too to see if I can find it.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] See, so you see how like some of your cardiology, there's some that were denied because office visits aren't covered and then some paid.
[AGENT][NEUTRAL] The coding is different, like they have like uh 99214, that's a place of service code, so that wasn't paid out, but then I see some here for like the actual services you got and those were all paid.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK, so.
[CUSTOMER][NEUTRAL] Which one are you looking at that wasn't paid?
[AGENT][NEUTRAL] So like um 3452786.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Sorry, my computer is just slow.
[AGENT][NEUTRAL] Oh, you're fine.
[CUSTOMER][NEUTRAL] Yeah, OK, so office visits aren't covered, so I just have to look up their code to even know what they're coding, I guess.
[AGENT][NEUTRAL] I mean, if, well, you mean like to file the claim or like you just want to look at the codes because you don't have to. They, they.
[CUSTOMER][NEUTRAL] Just
[CUSTOMER][NEUTRAL] Just trying to understand when I'm supposed to pay and when I'm not.
[AGENT][NEUTRAL] OK, but that
[CUSTOMER][NEUTRAL] Like if they're, cause sometimes I've found that like the doctor's office makes a mistake.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And so I'm just trying to understand on my end, am I supposed to pay the office visit co-pay, or like the standard one that is listed on, on your Blue Cross Blue Shield insurance, you know, like where it's to go to the primary care doctor, your office visit, co-pay is like $35 and then for a specialist, it's $70 just that like basic co-pay.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So this is two different things. So, Blue Cross Blue Shield charges the copays, we help pay it. So I can't really speak on if there's a co-pay and and the provider requires you to pay the copay to be seen, then yes, you'll have to pay that co-pay and then on the back end, once we, once it comes to us, we would or could be able to reimburse you.
[AGENT][NEUTRAL] You know how sometimes they say they can bill it. If they bill it, then you won't have to pay anything and we'll handle it on the back end, but most of the time now they're making us pay before we're seen.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So yes, if, if.
[CUSTOMER][NEUTRAL] Got you. OK, and so.
[CUSTOMER][NEUTRAL] Will you know if I've already paid or I guess I just have to submit that receipt then and keep track of what I've paid.
[AGENT][NEUTRAL] Well, so it depends. If you're filing the claim, then yeah, we always require the explanation of benefits from primary, so we can see everything that was charged, everything primary paid, everything you paid, and then what's left over.
[CUSTOMER][NEUTRAL] Mhm. OK.
[AGENT][NEUTRAL] And then if that's how we see, oh, she's paid $35 so we can go ahead and reimburse her or you know, from that explanation of benefits from [PII].
[CUSTOMER][POSITIVE] Gotcha. OK. All right. Well, thank you so much for your time. I do appreciate you helping.
[AGENT][POSITIVE] Well, you're very welcome. Was there anything else I can help with?
[CUSTOMER][NEUTRAL] Nope, I don't think so. Oh, actually, are you able to search if you've received any claims from a certain provider?
[AGENT][NEUTRAL] From a er
[CUSTOMER][NEUTRAL] Versus me having to click. So um Doogan and Walden Wellness, D O U G, let's see here.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh uh D O U G A N, Dugan and Walden, W A L D E N, Wellness.
[AGENT][NEUTRAL] Wow. OK. And this is for, it's for you or your husband or son?
[CUSTOMER][NEUTRAL] Um, it would have been for me and then, um, also my child.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Do you know like around when, because like for, for example, for you, we haven't received any claims since [PII], would it have been?
[AGENT][NEUTRAL] Like after that or before? OK.
[CUSTOMER][NEUTRAL] It would have been before that. It would, mhm.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] Um, there's
[CUSTOMER][NEUTRAL] And then even for my son.
[CUSTOMER][NEUTRAL] It's been since um
[CUSTOMER][NEUTRAL] I guess
[CUSTOMER][NEUTRAL] Mm, December.
[AGENT][NEUTRAL] December, OK.
[CUSTOMER][NEUTRAL] And I've been probably since like October.
[AGENT][NEUTRAL] Um, so this
[AGENT][NEUTRAL] There's really no way for me to search like by the provider, but I'm just going through each of the claims. There's not that many. Um, do you mind if I place you on just a brief hold?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] No, that's fine. Thank you.
[AGENT][NEUTRAL] OK, you're welcome. Hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] I don't see anything from Dugan.
[AGENT][NEUTRAL] 525.
[AGENT][NEUTRAL] 137.
[AGENT][NEUTRAL] 134.
[AGENT][NEUTRAL] 46.
[AGENT][NEUTRAL] 6049.
[AGENT][NEUTRAL] Nope, it's not here. Let's check for the baby.
[CUSTOMER][NEGATIVE] You are on hold
[AGENT][NEUTRAL] OK, hello, [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Thank you so much for holding. I apologize for that wait. So I went through your claims. I didn't see anything with that provider's name, um, and then for your son, we've only processed two claims, but I didn't see of those two that name.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][POSITIVE] OK, I will reach out to them because I don't think they're submitting them properly, um, which isn't surprising, um, so I will talk to them. OK, thank you so much.
[AGENT][POSITIVE] You're very welcome. Well, thanks for calling APL. I hope you have a great day and happy New Year.
[CUSTOMER][POSITIVE] Thank you. You as well. Bye-bye.
[AGENT][POSITIVE] Thank you. Bye bye.