AccountId: 011433970860
ContactId: 58c81992-da89-4621-a2de-59f0b2c7529f
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 616640 ms
Total Talk Time (AGENT): 167212 ms
Total Talk Time (CUSTOMER): 314641 ms
Interruptions: 1
Overall Sentiment: AGENT=0.4, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/26/58c81992-da89-4621-a2de-59f0b2c7529f_20250326T13:54_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yes, good morning. I submitted two claims and I've just been, uh.
[AGENT][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] They've just been processed and I just had a question as to why one of the claims didn't get paid.
[AGENT][NEUTRAL] OK, is it for yourself or you with a provider?
[CUSTOMER][NEUTRAL] For myself.
[AGENT][NEUTRAL] OK, thank you. Um, what was your name and do you have a good callback number?
[CUSTOMER][NEUTRAL] My name is [PII], phone number [PII].
[AGENT][NEUTRAL] OK, [PII], do you have your policy number?
[CUSTOMER][NEUTRAL] Yes it is.
[CUSTOMER][NEUTRAL] 01975687 M as in Mary, L as in Larry 8.
[AGENT][NEUTRAL] OK, I just need to verify a few pieces of information. Do you have your date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And your address?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And then lastly your email address.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Uh, it looks like it's a work address.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Yes, thank you.
[AGENT][NEUTRAL] OK, and we wanted to check on a claim denial, is that correct?
[CUSTOMER][NEUTRAL] Yeah, I just never done this and it's, it's very confusing to me so I just thought I'm just trying to get on the learning curve here because I just had, I recently had an accident so I'll be having claims coming through again so I wanted to make sure that I did it correctly for my previous claims.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Did you get a claim number on that?
[CUSTOMER][NEUTRAL] I did, um, I think it's, I think it's O as in Oscar, S as in Sam, C as in cat, 95274.
[AGENT][NEUTRAL] Let's see
[AGENT][NEUTRAL] OK, so it looks like.
[AGENT][NEUTRAL] That was processed and we made a payment of 500.
[AGENT][NEUTRAL] Let me see.
[CUSTOMER][NEUTRAL] That was the other claim that was the 95,270.
[AGENT][NEUTRAL] OK, let me see.
[CUSTOMER][NEUTRAL] They put those together. I submitted them separately but they processed them together. I don't know why, but they did.
[CUSTOMER][NEUTRAL] So the one claim that I got for the hospital for the emergency at $500 apparently they're paying that but the other one was a total of $200 and it looks like they're not paying that so I was wondering why.
[AGENT][NEUTRAL] OK, let me see.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Uh, there was one on here for office visits.
[AGENT][NEUTRAL] Um, which aren't covered by the policy.
[AGENT][NEUTRAL] Um, let's see.
[CUSTOMER][NEUTRAL] So co-pays are not covered?
[AGENT][NEUTRAL] So any charge for office visit besides treatment and procedure performed in the office, the actual office visit itself is not covered.
[CUSTOMER][NEUTRAL] OK, because I was told differently when I called APL they said the copays were covered, so that's where my confusion was.
[AGENT][NEUTRAL] Yeah, we potentially based on whatever policy you have copays could be covered, but for this policy, the actual office visit itself is not covered.
[CUSTOMER][NEUTRAL] OK, good to know.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then was there another, uh, question on the claim?
[CUSTOMER][NEUTRAL] No, I'm just looking at the claim because.
[CUSTOMER][NEUTRAL] One of them was $50 for Explore Wound Extremity and I had to pay $50.00 that was $100 and the office visit and the and the 95274, the one that I'm in question of there was um.
[CUSTOMER][NEGATIVE] One was for the urgent care and that was $100 co-pay so apparently that's denied as you just explained, but then the second one that was there for $100 there was an office visit at $50 but then there was an explore wound extremity that they that I had to pay $50 out of pocket.
[AGENT][NEUTRAL] Um, let's see which one
[CUSTOMER][NEUTRAL] So I don't know why that was.
[AGENT][NEUTRAL] Let me pull up the actual claim. I look at what we've got here.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, these were plans like I said I.
[CUSTOMER][NEUTRAL] At the time I didn't know how to do it and I kept submitting it and they kept denying it and so finally I said I gotta sit down and figure out exactly what needs to be done so I just did it last week.
[AGENT][NEUTRAL] Yeah, yeah.
[CUSTOMER][NEUTRAL] Insurance isn't one of my faves.
[AGENT][NEUTRAL] Just
[AGENT][NEUTRAL] Uh, I totally understand. Yeah, it gets quite complicated.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][POSITIVE] It can be kudos to you guys. I don't know how you guys do it every day.
[AGENT][NEUTRAL] Uh
[AGENT][POSITIVE] Thank you. Well, we're here to help and I, I'm sorry, it was, I'm sorry it was not a seamless process. We don't like to hear that, but.
[CUSTOMER][POSITIVE] Hm, no worries.
[CUSTOMER][NEUTRAL] Yeah, that's right, uh, going forward, like I said, I, you know, I always, I forget to put a lot of the, like a lot of people don't take the APL when you go to visit, you know, doctor's office. They say, oh no, we won't, we don't take that so it's, I guess it's just on, on my, you know, the patient's responsibility to do the claims going forward at the end of the day.
[AGENT][NEGATIVE] Yeah, and it's kind of that's kind of frustrating because it's like it is a supplemental policy and I don't know why they wouldn't you know accept it and file things for you.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] I'm gonna have to make sure I carry it. I, it's something new to me too. I've never had that, so that's another reason it's all new to me, the secondary, um, medi Medicare or medical.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Coverage
[AGENT][NEUTRAL] I was trying to see, OK, so we were looking at, there was another $50 charge, is that correct? that you were asking about that why it denied.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, let's see.
[CUSTOMER][NEUTRAL] Yeah, it, I see the office visit. It's on the, the bottom. It's there's two of them, 1 $100 which was on the first on the first top part, um, for the urgent care that I went to, so I had to pay a co-pay $100. So that's, I guess that's not covered, but underneath that there was another office visit that's when I had to go to a hand surgeon because I accidentally stabbed myself.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] And so naturally that office visit I guess $50 it was my co-pay, but underneath there there's another $50 that they they um.
[CUSTOMER][NEUTRAL] They cared for my wound, so they charged me if you see amount billed $945 and it says member.
[CUSTOMER][NEUTRAL] Plan paid $6643.46 but then I paid $50.
[AGENT][NEUTRAL] OK, I'm pulling up your.
[AGENT][NEUTRAL] Original claim submittal so I can see what exactly.
[AGENT][NEUTRAL] Looking at, OK, I see where you're 9:45.
[AGENT][NEUTRAL] OK, I see that you said explore wound extremity.
[CUSTOMER][NEUTRAL] Yes, yes.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, it looks like.
[AGENT][NEUTRAL] Well, it showed that the plan paid 100%, but then, OK, it was the co-pay, it didn't allow the co-pay. Um, so looks like on this policy it's allowing your co-insurance and deductible amounts.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So yeah, that's, that's what that was.
[CUSTOMER][NEUTRAL] OK, so that's being denied because that was an office visit as well, I guess.
[AGENT][POSITIVE] Correct, like it was bundled with the office visit, yeah.
[CUSTOMER][NEUTRAL] OK, OK, and then since this is my first time uh doing any kind of claims, I see that I, there's an um opportunity to set up a direct deposit. Is it too late for that $500 to go direct deposit or I don't know how quickly they turn around and pay those amounts.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah, let me see, I think so.
[AGENT][NEUTRAL] Yeah, at this point.
[CUSTOMER][POSITIVE] It probably makes it easier for both.
[AGENT][NEUTRAL] Yeah, at this point it would be too late, but, um, be sure and go to the uh online portal and get that set up and then in the future you can have the direct deposit.
[CUSTOMER][NEUTRAL] Uh huh.
[CUSTOMER][POSITIVE] OK, yeah, I'm sure it makes it easier for both of us so OK great alright I just wanted to double check so um I think going forward I'll be able to do this seamless seamlessly.
[AGENT][POSITIVE] Yeah, just faster.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][POSITIVE] But OK, well thank you so much for your help I really appreciate it.
[AGENT][POSITIVE] OK, thank you, [PII]. I hope you have a great day and thank you for calling APL.
[CUSTOMER][POSITIVE] OK thank you bye bye.
[AGENT][NEUTRAL] Bye.