AccountId: 011433970860
ContactId: 5a10ea54-98c1-4cf1-aaef-2af08785d4a9
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 905200 ms
Total Talk Time (AGENT): 364663 ms
Total Talk Time (CUSTOMER): 517324 ms
Interruptions: 7
Overall Sentiment: AGENT=0.5, CUSTOMER=-0.9
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/07/5a10ea54-98c1-4cf1-aaef-2af08785d4a9_20250307T17:57_UTC.wav
--------------------------------------------
[AGENT][POSITIVE] Good afternoon thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII]. I'm calling regarding a couple of claims claims I filed.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So I got the I got the letter that I need in the EOB.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I called my insurance company.
[CUSTOMER][NEUTRAL] And they cannot relocate all the EOBs. We called actually together with them to the hospital to verify that it's through them. They gave them the same insurance that they have. They just cannot find it.
[CUSTOMER][NEUTRAL] Um, I'm, I'm in a place that I don't know what to do because I have a proved that I paid.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] I'm not sure what can I do now if the insurance cannot find the UB.
[AGENT][NEUTRAL] OK. Do you have your policy number available?
[CUSTOMER][NEUTRAL] Uh, with the APL.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Um, I actually don't have it currently. I can give you some other identification.
[AGENT][NEUTRAL] I can pull it up by your social if that's OK.
[CUSTOMER][NEUTRAL] Yes, yeah, and with [PII].
[AGENT][NEUTRAL] I'm sorry, can you give me that account number again? And then, and I need the complete number.
[CUSTOMER][NEUTRAL] Uh, uh, a complete number. I actually can't find it in it.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Yes, it's [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And do you mind verifying your name again?
[CUSTOMER][NEUTRAL] Sure, call me [PII]
[AGENT][NEUTRAL] Thank you. And Miss [PII], what is your date of birth, please, and current mailing address?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII] and [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And you're stating that your primary insurance cannot locate the EOB or explanation of benefits?
[CUSTOMER][NEUTRAL] Explanation of benefits um.
[CUSTOMER][NEUTRAL] I mean, I'm sure they can give me explanation of benefits. It's not something specific, right?
[AGENT][NEUTRAL] Right, so, uh, so.
[CUSTOMER][NEUTRAL] Yeah, yeah, so the explanation of benefits that I think I can call them and ask for that specific day because that's something they don't need to look for, uh, something specific for me, but the EOB, so I asked for these days and they send me these days and it's not treat during in these days and I paid for that and they covered and we called both hospitals because they have a couple of hospitals that it happened like the ER.
[CUSTOMER][NEUTRAL] And they're giving them my insurance with my policies, and they tell me, OK, you just transferring to a higher one, higher one, higher one, and I'm just waiting for that for a couple of weeks. I don't know what to do and they told me, but you have the proof that you say. I said yes, but the secondary insurance, I don't know, the you'll be uh that's what they want.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] I don't know what this is.
[AGENT][NEUTRAL] OK, so the explanation of benefits, so your policy is secondary, was secondary to your primary. That explanation of benefits is gonna show us what they applied to your deductible, co-pay or co-insurance.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Of your for that service.
[CUSTOMER][NEUTRAL] OK, so just let me, uh, just let me please write it down that I'm gonna ask them that specific thing.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, OK.
[CUSTOMER][NEUTRAL] So I'm gonna call them so I need to get an explanation of benefits.
[AGENT][NEUTRAL] Mhm. Now that is how you, that will show us how your primary insurance process the claim and what they paid and what they applied to a deductible co-pay or co-insurance for those dates of service.
[CUSTOMER][NEUTRAL] So how primary insurances uh file a claim? What? Sorry, I'm just writing it to tell them how primary insurance doing what?
[AGENT][NEUTRAL] Mhm. Sure. So.
[AGENT][NEUTRAL] How they process the claim and what they applied to your deductible.
[AGENT][NEUTRAL] Co-pay or co-insurance. So the explanation of benefits is what your primary insurance will send you after they process the claim.
[AGENT][NEUTRAL] Showing what they paid and what they applied to your deductible co-pay or co-insurance.
[CUSTOMER][NEUTRAL] So it can be it doesn't need to be specific for the dates I had, but it can be something general how they processing my claims basically, right?
[AGENT][NEUTRAL] It, it would be general. It would be specific to that data service for [PII] and [PII].
[CUSTOMER][NEUTRAL] OK, OK, I, I'm gonna write.
[CUSTOMER][NEUTRAL] OK, that, yeah, that's not a, yeah, that's I'm saying because they, they, they, I don't know how they lost something like that sounds insane, but uh, OK, uh, so what they will take specific to the date of the, yeah, I have the same insurance that's.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, so I can, uh, I'll just send that and that's OK. Now I have another question. I hope that will be OK. Uh, couple of things. First of all, if I went to the hospital but I did not involve my insurance.
[CUSTOMER][NEUTRAL] Meaning I did some uh examination and they told me that if I'm doing it out of pocket it's cheaper so I didn't use my primary insurance. Can I file a claim for that or that's not eligible for that?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So we, this policy would only pay if your primary insurance processes the claim and applies [PII]ing to your deductible to pay your full insurance.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so fine. So that's the one to submit this one and I have last one last one and so it's also I read about it. It's also diagnostic thing. So by diagnostic if I took my, my son, for example, fractured his um.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And he went to, so it was an ER went into some office, they did the the X-rays, whatever.
[CUSTOMER][NEUTRAL] Uh, you, and I obviously I use my insurance, but you, uh, paying part of that as well, or that's just for ER or something like that.
[CUSTOMER][NEUTRAL] The hospital.
[AGENT][NEUTRAL] Let me get those benefits pulled up. Let me just take a look real quick.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] Oh, my pleasure.
[AGENT][NEUTRAL] So the policy would have paid for emergency room, urgent care facility.
[AGENT][NEGATIVE] Um, if it was in a doctor's office, it would not be covered.
[CUSTOMER][NEUTRAL] So also if it's like a diagnostic, any diagnostic thing in office will not be covered.
[AGENT][NEUTRAL] That's right. And they went to a diagnostic center or outpatient hospital, urgent care, or emergency room.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] The what do you mean by diagnostic center like what?
[AGENT][NEUTRAL] Um, like an outpatient facility?
[AGENT][NEUTRAL] Diagnostic Center.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] MRI facility.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] I like, I like MRI but out of office.
[AGENT][POSITIVE] That's right.
[CUSTOMER][NEUTRAL] OK, and, uh, OK, so that will be OK, so I, again just I can just add these, uh, things to my insurance for these specific dates and that will be fine. I don't know what to do at that point.
[AGENT][NEUTRAL] That's right. So yeah, so when you call Cigna, ask them for the explanation of benefits for data service 51122.
[CUSTOMER][NEUTRAL] OK, just the explanation without my specific because they can't find it. OK, fine, thank you.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah, so it had to be filed by them and that it will let us know what they applied after they processed the claim.
[CUSTOMER][NEUTRAL] What, what if they like what? What? Sorry?
[AGENT][NEUTRAL] So yeah, so what happens is um once they receive a claim, Cigna is going to process that claim and then they send you what's called an EOB or explanation of benefits on that explanation of benefits is going to have specific information.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] For that date, for that claim. It'll tell us what they pay toward that claim and what they applied to your deductible, co-pay or co-insurance.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, but that's what they cannot find that's what I told you they cannot.
[AGENT][NEUTRAL] That's what we're gonna need.
[CUSTOMER][NEGATIVE] But is that's exactly the problem.
[AGENT][NEUTRAL] Do you have their website? Maybe a website for them?
[CUSTOMER][NEGATIVE] I, yeah, and I, I have the website, but it's 3 years ago and the website, but they, they also they send me the EOB it's just not written in the EOB.
[CUSTOMER][NEGATIVE] And it's not clear why so they just transferring to a higher manager, higher manager, whatever, but they just cannot find it. So that's why I told you. I don't know what to do because I had a proof that I paid and if we call the hospital which I paid for, they're gonna give you, they prove to you. I don't know exactly how, but with my insurance number that they did apply, that's why I didn't pay 1000 and I say 300.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] Got you.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, did the insurance pay the hospital for those dates?
[CUSTOMER][NEUTRAL] Yes, yeah, of course, otherwise I wouldn't be such as normal.
[AGENT][NEUTRAL] So maybe your hospital.
[AGENT][NEUTRAL] Maybe your hospital has that EOB or explanation of benefits.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And the hospital has the ELB.
[AGENT][NEUTRAL] They could.
[CUSTOMER][NEUTRAL] And I, uh, I can try. I'm not sure they have. I mean, but if the hospital, I mean, in the bill of the hospital, it's written how much they charge and how much I paid.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So the rest and they read and it's written actually how much the insurance pay them.
[CUSTOMER][NEUTRAL] But that's like I have just the the numbers. I did not like writing like a letter of explanations. I don't know.
[AGENT][NEUTRAL] Yeah, so
[AGENT][NEUTRAL] Right. So we're gonna have to have that though from your primary because we are secondary to your primary insurance.
[AGENT][NEUTRAL] So we'll have to have that from Cigna.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Yeah, but if, but if actually if I'm, if I'm sending in the hospital, the hospital bill like it's sweet and how much they filed, how much I was supposed to pay like in total and how much I practically paid.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] It wouldn't be enough.
[AGENT][NEUTRAL] Yeah, it would not. We would have to have that specifically from Cigna since we are secondary to Cigna. That's why we have to have it from Cigna.
[AGENT][NEUTRAL] But I'm sure that if Cigna paid them, then the hospital did receive a copy of that EOB. Do you still owe the hospital? Or no, you already paid. Yeah, you already paid.
[CUSTOMER][NEGATIVE] No, I, I paid, no, I paid years ago.
[AGENT][NEUTRAL] Yeah, and we need to reimburse you for that payment.
[CUSTOMER][NEUTRAL] I said it to you.
[CUSTOMER][NEUTRAL] I mean, I have the receipt actually. I I mean the receipt. I have the number like you have always like a number approval.
[AGENT][NEUTRAL] I.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Like
[AGENT][NEUTRAL] Right, for your payment. Yeah.
[CUSTOMER][POSITIVE] That you paid I have that. Yeah, I have that. I have, I have the numbers. I have the, the hospital was OK, gave me all the receipts and everything, and they can were able even to pull my insurance that they charged.
[AGENT][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] But I know the Florida Blue Cross Blue Shield just they cannot find it.
[CUSTOMER][NEUTRAL] And we call to get her to the hospital.
[AGENT][NEUTRAL] You know, if you had, now Florida Blue Cross Blue Shield, did you say you're
[AGENT][NEUTRAL] Insurance was Cigna or was it Florida Blue?
[CUSTOMER][NEUTRAL] Florida blue like the shield.
[AGENT][NEUTRAL] For that, for those dates?
[CUSTOMER][NEUTRAL] Mhm, yeah, yeah, it's still [PII]. I, I have the same insurance. My primary is [PII].
[AGENT][NEUTRAL] OK, let me tell you
[AGENT][NEUTRAL] Ask them if we have a health, if they have the health statement. H E A L T H.
[CUSTOMER][NEUTRAL] H E L C E uh health statement.
[AGENT][NEUTRAL] Statement.
[AGENT][NEUTRAL] Mhm. Mhm. For each of those dates of service, [PII] and [PII], if it's [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] They, they have the the date but it's not written the.
[CUSTOMER][NEGATIVE] The thing they got, you know, it's not written there although it happened and they pay for it when they pull in there that the EOB, which is the health statement, it's just not written there. They cannot find it. They cannot relocate it.
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] Well, that just sounds crazy, doesn't it?
[CUSTOMER][NEUTRAL] Uh, it, it, I'm telling you, and we were called together to the hospital, more than one hospital, both of [PII] and [PII], whatever, and we're talking to the representative there and they told him, and they tell them, OK, from where you charge it, and they're giving them by themselves, my insurance.
[AGENT][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] My like my details and they said, oh, OK, so it's the same one so OK so I'm gonna transfer it to my manager so that.
[AGENT][POSITIVE] Oh my goodness.
[CUSTOMER][NEGATIVE] I, I know it's like it's really insane. I don't know how, and it's crazy because they pay. It's not like something that they need to hide.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEGATIVE] I, I, I, I just cannot get it.
[CUSTOMER][NEGATIVE] How come and they send me over and over again the May statement.
[CUSTOMER][NEGATIVE] With the client, it doesn't help me.
[AGENT][NEUTRAL] No, and I am so sorry, but we do have to have something from Florida Blue showing what they applied to your deductible, co-pay or co-insurance.
[CUSTOMER][NEUTRAL] It's not in there.
[CUSTOMER][NEUTRAL] And if they're gonna send you like what they would have done and you're gonna see it's matching.
[CUSTOMER][NEUTRAL] What they did
[CUSTOMER][NEUTRAL] Based on these dates and the insurance I had.
[AGENT][NEUTRAL] Right, right.
[CUSTOMER][NEGATIVE] That won't be enough.
[AGENT][NEUTRAL] No, we will have to have that from Florida Blue showing what they applied to the deductible co-pay, or co-insurance for those dates.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEGATIVE] So if they're not sending in just like the money disappeared basically.
[AGENT][NEUTRAL] And then once we have that, you know, we can process the claim, but if you have their website, go under claims details and look for the help statement for those dates of service maybe you can locate it that way.
[CUSTOMER][NEUTRAL] No, I can't. I cannot for sure because it's over 3 years ago.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] But they tried to do it with me and they couldn't find it.
[AGENT][NEUTRAL] It's probably because of the time frame.
[AGENT][NEUTRAL] That it was
[CUSTOMER][NEUTRAL] I know, but they were able to send me the May, they were able to send me that month.
[CUSTOMER][NEGATIVE] But that service was not written there.
[AGENT][POSITIVE] Oh my goodness.
[CUSTOMER][NEUTRAL] Yeah, they found him on
[CUSTOMER][NEUTRAL] Without that service.
[AGENT][NEUTRAL] They found the.
[AGENT][NEUTRAL] But the hospital, but Florida Blue did pay the hospital. That's, oh.
[CUSTOMER][NEUTRAL] That's why we called today sure. The hospital, yeah, they have.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEGATIVE] I said I don't know what to do and we called together. I called with Florida Blue Cross Blue Shield to the hospital because they thought maybe like the some, I don't know, I don't know what they even thought.
[AGENT][NEUTRAL] Well
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And they said you pay that. I said, OK, we cannot say find what you pay.
[AGENT][NEUTRAL] Yeah, if you call them back, ask to speak to a supervisor maybe a supervisor.
[AGENT][NEUTRAL] Can help you.
[CUSTOMER][NEUTRAL] Yeah, I try.
[AGENT][POSITIVE] Yeah. Yeah, but that's what we have to have. I'm so sorry.
[CUSTOMER][NEUTRAL] OK, the supervisor and they just can't find.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] It's been my pleasure, Ms. [PII]. Thank you for calling APL and I hope you have a lovely weekend.
[CUSTOMER][NEUTRAL] Uh