AccountId: 011433970860
ContactId: 67526b10-4c3a-4149-ae5c-7195cb4085f2
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 520658 ms
Total Talk Time (AGENT): 149896 ms
Total Talk Time (CUSTOMER): 314956 ms
Interruptions: 0
Overall Sentiment: AGENT=0.3, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/06/67526b10-4c3a-4149-ae5c-7195cb4085f2_20250106T17:48_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. My name is [PII]
[AGENT][NEUTRAL] How can I help you today, [PII]?
[CUSTOMER][NEUTRAL] I have y'all
[CUSTOMER][NEUTRAL] Yes ma'am, I, um, you know, y'all are our, you, you're our gap insurance company that I guess you manage our deductibles, um, I have a policy number. Would that help you to kind of pull up who I am or whatever or are you good?
[AGENT][POSITIVE] Yeah, absolutely. Policy number is always helpful. Um, you can give me that whenever you're ready.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes ma'am, it's 01612917.
[AGENT][NEUTRAL] OK, so I've got that pulled up here, [PII].
[CUSTOMER][POSITIVE] OK, we're good.
[AGENT][NEUTRAL] What kind of questions did you have today?
[CUSTOMER][NEUTRAL] OK, I am being currently treated by Methodist Hospital in [PII], which is in-network and our primary insurance is United Healthcare, OK?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And I'm just, I, I, I am calling just to communicate, um, so I'm sure you will be seeing, I mean, how does it work? The claims go to United Healthcare and then my deductible is $250.
[CUSTOMER][NEUTRAL] And that covers the uh my part is $250 of a $5000 deductible I guess y'all manage that deductible for us, am I correct?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. So, um, I mean, how does it all work? Uh, because, uh, I, I'm being treated by the, uh, the Methodist Hospital wound Center, OK? And they have, they have ordered all of this medical stuff that I have to use for my non-feeling, non-healing situation and um they're called community medical supply, but they were.
[CUSTOMER][NEUTRAL] You know, it goes through Methodist, and um, you know, now they're calling me and said that they called y'all and, and they talked to [PII], [PII] said that they're not covered, etc. etc. and I just want to see, you know, how does it all work and um.
[CUSTOMER][POSITIVE] Make sure I get all this taken care of correctly.
[CUSTOMER][NEUTRAL] That makes sense?
[AGENT][NEUTRAL] Yeah, so, OK, yeah, I mean usually what would happen in those situations, [PII] is, you know, you provide the insurance to the provider themselves, they bill the primary and then send anything remaining to us, um, and then, you know, that's processed whether or not.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It's covered under the plan or not um so they're saying that they've received some denied claims from us, is that what they're saying?
[CUSTOMER][NEUTRAL] Well, they, uh, they called me this morning, you know, and they said, OK, we sent you these bandages and all this kind of stuff, and that, and, and I said, well, I have, you know, this is who manages our, our deductible was APL and it's United Healthcare is my major one. So basically, they need to file initially with United Healthcare, am I correct?
[AGENT][NEUTRAL] Right, they would, uh-huh.
[CUSTOMER][NEUTRAL] OK, and then, and then United Healthcare, uh, would tell them how much of that they're gonna pay, you know, this, I'm being facetious if it's a, a $50 roll of tape, they're gonna say I'm gonna pay you $10 you know, and, um, and then it goes from there, OK, because they sent me an email about.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Right, right.
[CUSTOMER][NEUTRAL] You know, you know, for coverage, da da da da, and I'm just gonna reply back, you need to file with United Healthcare and I can give them my, my group number and all that kind of stuff, and that's who they would file with, OK.
[CUSTOMER][NEUTRAL] And I know that insurance takes a while to get all worked out, you know, and, and don't pay anything until it's all worked out, am I correct? Pretty much.
[AGENT][NEUTRAL] Yeah, absolutely. And you should be able to, if you haven't, like, um, both insurances ourselves and United Healthcare, who's your primary, I mean, you should be able to see a breakdown of what they submitted to United Healthcare on the explanation of benefits, what was paid by them.
[AGENT][NEUTRAL] And then we would do the same, you know, the X amount of dollars was submitted to us as residual, um, we either paid or denied based, you know, and it would give an explanation as to why X amount of dollars was paid or if it was denied the reason why.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, would you ever, I mean in your profession, I mean if this is a medical supply company that that Methodist Hospital contacted that they use and representing them, OK, could you imagine why they would say we're not gonna cover this? You know what I'm saying? That's just kind of crazy. I'm all I'm doing is I'm just a patient.
[CUSTOMER][NEUTRAL] Doing what they told me to do and and receiving the information that they told me that I needed to get.
[CUSTOMER][NEUTRAL] So I mean that's just how it all worked, you know.
[AGENT][NEUTRAL] Mhm, mhm.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] I mean, medical.
[CUSTOMER][NEGATIVE] Probably can't answer that question.
[AGENT][NEUTRAL] I mean, medical equipment, it's kind of like, uh, let me, I'm trying to see.
[CUSTOMER][NEUTRAL] And it didn't even equipment, it's, it's basically, um, you know, gauze and pads and uh cleaner and uh tape, and that kind of stuff, you know.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah I mean I don't.
[AGENT][NEUTRAL] I mean, I don't see anything. I mean, I could definitely if there was, if we had a denied claim, we could look into it and see exactly, you know, if there was.
[CUSTOMER][NEUTRAL] But you don't, you don't even see a denied claim yet? No.
[AGENT][NEUTRAL] Let me
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Do you know what the facility would be by chance or like the facility name?
[CUSTOMER][NEUTRAL] It's called Community Medical supply.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And I'm sure it's some clerical person that you know, OK, we sent this to this dude and now we need to get paid and just going through the process.
[AGENT][NEUTRAL] Right, yeah, I mean, I don't see anything recently for community medical supply that's been submitted on our side.
[CUSTOMER][NEUTRAL] OK, well I'm gonna go ahead and just reply back. I need to contact United Healthcare.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And we'll see where it goes, but I just, I just wanted to make, go on record that, you know, y'all should be seeing some claims coming from the Methodist Hospital, wound wound center to United Healthcare, and they are definitely in-network, OK? And um I'm just going through a tough time trying to get this problem taken care of.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right, [PII], yeah, I'll notate our conversation and the concerns and just that the claims should be coming through here and if you have any other concerns or questions feel free to call us.
[CUSTOMER][NEUTRAL] Well, the whole project, so you get a little history, the whole process started back in September.
[CUSTOMER][NEUTRAL] Uh, I have a staph infection. They did surgery through, through, um, Memorial Herman in [PII]. It, it healed after 3 weeks, OK. Uh, I was walking in a park with my [PII] grandson, and he came up from behind me. I didn't know it, and he hit me and I came right down on my knee and opened it back again. OK?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And then he, um, they had to clean it out. It didn't heal, they had to open it up again. But y'all have been, UnitedHealthcare has been paying all of these claims, and what I'm going through now is just the ongoing end of it to try to get this thing to heal. You know, it's all part of the same case, the same case. So, OK, well, thank you so much. Let's see where it goes.
[AGENT][NEUTRAL] OK. Yeah.
[AGENT][NEUTRAL] Right, right.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] All right, [PII], thanks for calling. Have a good rest of your day.
[CUSTOMER][NEUTRAL] You bet bye bye.
[AGENT][NEUTRAL] Bye bye.