AccountId: 011433970860
ContactId: 63437d89-c065-42a1-abd9-6705ed71abab
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 893510 ms
Total Talk Time (AGENT): 372775 ms
Total Talk Time (CUSTOMER): 165824 ms
Interruptions: 6
Overall Sentiment: AGENT=0.4, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/31/63437d89-c065-42a1-abd9-6705ed71abab_20250331T19:32_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, yes, I'm calling because it appears I have two claims, uh, that were denied. I'm trying to figure out exactly why.
[AGENT][NEUTRAL] OK, I can check on that. I can assist you with claim status. And may I have your name and a callback number just in case we get disconnected?
[CUSTOMER][POSITIVE] Perfect
[CUSTOMER][NEUTRAL] Your first name is [PII]. Last name is spelled [PII]
[CUSTOMER][NEUTRAL] And my phone number is [PII].
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Alright, well I'll see you tomorrow.
[AGENT][NEUTRAL] Thank you. Do you have the policy number, Miss [PII]?
[CUSTOMER][NEUTRAL] Mm, I am logged in.
[CUSTOMER][NEUTRAL] Online.
[AGENT][NEUTRAL] The policy number is in blue.
[CUSTOMER][NEUTRAL] I'm sure it's gonna be on here somewhere.
[CUSTOMER][NEUTRAL] Oh, sure. It's right there. That is uh 240-435-5.
[AGENT][NEUTRAL] OK, thank you. And for security, may I have your date of birth, mailing address and email address on file?
[CUSTOMER][NEUTRAL] [PII] [PII] and my email address is my [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Can you see [PII] on that address?
[CUSTOMER][POSITIVE] Correct.
[AGENT][POSITIVE] OK, sure. All right, thank you.
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so there's one we paid, when we denied. OK, so the ER was paid up to 50. Let me check which one we denied.
[CUSTOMER][NEUTRAL] And there were 2 that weren't.
[AGENT][NEUTRAL] OK, let me look at this one.
[CUSTOMER][NEUTRAL] Paid
[CUSTOMER][NEUTRAL] There's another one that should have been submitted a couple of weeks ago and I'm not seen, so I have to get a hold of my doctor regarding that.
[AGENT][NEUTRAL] OK, alright, let me pull that you be one moment.
[CUSTOMER][NEUTRAL] How
[AGENT][NEUTRAL] Yeah, I'm waiting on the paperwork, bear with me.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] Mm.
[AGENT][POSITIVE] benefits.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so that one is saying that it was fully paid by the major medical. Let me see if it's just not a um.
[AGENT][NEUTRAL] When there's not an amount applied towards the deductible copayment and co-insurance, that's when we deny stating that there was nothing or there was all paid by the major medical, um, so let me just go ahead and see.
[CUSTOMER][NEGATIVE] It's not because I just, I just got a bill again today or yesterday in the mail for those two appointments.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me check and see what exactly is showing up on the EOB.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] Um, you're welcome.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Do you mind holding for me just a minute? I'm just waiting on the documents.
[CUSTOMER][NEUTRAL] Of course.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Thank you for holding and being patient for Mr. [PII].
[CUSTOMER][NEUTRAL] Of course, that's fine.
[AGENT][NEUTRAL] OK. Under the cardiology of the Florida, they have charged that twice, but um the explanation of benefits they're sending from Blue Cross Blue Shield is indicating they're only allowing $33.01 and that is what they pay, the $33.01.
[AGENT][NEUTRAL] Um, how much are they trying to charge you?
[CUSTOMER][NEUTRAL] Um, $60 per visit. So they're showing them $120 but my understanding this insurance is supposed to cover that co-pay.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] It doesn't look like we have received that. Um, again, the only thing that um I see here and that's, it's coming directly from them, from the cardiology, um, it's indicated that
[AGENT][NEUTRAL] OK, um, based on the, so the total charge they are charging is $66 and Blue Cross Blue Shield is only allowing $33.01 and that is what they're sending in. So I'm not sure if they're just charging something different that they're not sending us, but if it's that.
[CUSTOMER][NEUTRAL] No, so, so, so my, yeah, my, my co-pay with this doctor is $60.
[CUSTOMER][NEUTRAL] My understanding is the supplemental insurance is supposed to, it's this gap insurance that should cover that $60 am I incorrect in my understanding of this insurance?
[AGENT][NEUTRAL] Um, let me check because if it's just for the visit itself, it may be not covered because we cover procedures, um, but sometimes we do not cover the office visit itself. So let me look at your benefits really quick then.
[CUSTOMER][POSITIVE] OK. Thank you.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK here's your certificate.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Outpatient. OK. So yes, this one only covers the office treatments and procedures. It does not cover the office visits. So the co-payment for the office visit, we do not cover.
[CUSTOMER][NEUTRAL] And so, uh, it doesn't cover things like even if it's there's an EKG that's done, anything like that is not considered.
[AGENT][NEUTRAL] Yes, any procedure. So an EKG, an ultrasound, a sonogram, um, anything like that, any procedures done or any treatment done in the office, that's what we cover. What we do not cover is the visit itself.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So each
[CUSTOMER][NEUTRAL] For each of those visits I did have an EKG done.
[AGENT][NEUTRAL] Hm. Is that what they're trying to charge, the EKG?
[CUSTOMER][NEUTRAL] I, I have no idea. I'm, I'm not an insurance expert. I know that I have this insurance, this gap insurance is supposed to cover this.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Mhm. Yeah, I
[CUSTOMER][NEUTRAL] And that's why I'm trying to figure out why it's not being paid.
[AGENT][NEUTRAL] And I do understand, but what they're charging here, and again I'm just looking at what I see. I can only see of what they have sent us and what we have processed, OK, based on what they have sent us, OK? Um, there is a charge [PII] for $66 OK? Um, let me see if there's any way I can pull the procedure and check and see exactly what is this for.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Yeah. OK, and this is the EK ECG. Well, this is an ECG, electronic cardiogram. OK, so this is what they're charging. Now, again, we are the secondary, so we, what we do is we follow primary, OK? So Blue Cross Blue Shield is saying that they only allow $33.01 for this type of procedure, OK?
[AGENT][NEUTRAL] So they pay the $33.01.
[AGENT][NEUTRAL] So it should be fully paid by the major medicals. So I'm not really sure why you're getting those bills. So at this point, um, since we already processed and we are going by what Blue Cross Blue Shield is saying.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] The best thing is to go back to Blue Cross Blue Shield and ask them why, why are you getting those bills when they're paying the full amount. Are are they're not getting the checks or what's happening because they're fully paid by the major medical based on the explanation of benefits that was given to us.
[CUSTOMER][NEUTRAL] But I, I think you're missing the fact that I, I saw that a $60 co-pay for each visit.
[AGENT][NEGATIVE] Again, we do not cover the visit. We do not cover the visit. If they're charging just the visit, we do not cover the visit. If they're charging the procedure, which that's what I'm looking at here. I'm looking at the procedure, and they did send it to us, but it was fully paid by Blue Cross Blue Shield, so I'm not really sure why, why are they sending you a bill for that.
[CUSTOMER][NEUTRAL] So you're saying that the insurance cover you.
[AGENT][NEUTRAL] Because it was fully paid by the major medical.
[CUSTOMER][NEUTRAL] OK, I will get a hold of our HR department and see if they can help explain how this benefit is supposed to work because that's not how it was presented, um, but I will, I appreciate your help. I will, um, see what I can find out.
[AGENT][NEUTRAL] Again, I, I see that the dis the disconnect is between the provider and the major medical. So to get this resolved, you need to contact the major medical. I think they will give you a better explanation because it is, um, it came to us for the electrocardiogram, but there's nothing for us to pay because they were paid fully by the major medical by Blue Cross.
[CUSTOMER][NEUTRAL] OK. OK. I have one other question. How long after, um, uh, a procedure or an appointment do you have to submit a claim?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] There's no timely filing limits for submission.
[AGENT][NEUTRAL] But um usually if you're gonna submit your own claim, we need the explanation of benefits from the primary insurance, so you need to wait until you receive that to process your own claim.
[CUSTOMER][MIXED] OK, but there's no set time frame as to how.
[AGENT][NEUTRAL] No.
[AGENT][NEGATIVE] How old the claim? No, no, there's no set time. No.
[CUSTOMER][NEUTRAL] How far back you can go.
[CUSTOMER][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK. I appreciate your help. Thank you so much.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] You're welcome. Is there anything else I may help you with today?
[CUSTOMER][NEUTRAL] Bye.
[CUSTOMER][POSITIVE] That is it for now. Thank you.
[AGENT][POSITIVE] OK. Have a good day. You're welcome. Bye-bye.