AccountId: 011433970860
ContactId: 6c7d9034-c552-491a-97de-835f6d9a4bca
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 744719 ms
Total Talk Time (AGENT): 530582 ms
Total Talk Time (CUSTOMER): 158753 ms
Interruptions: 2
Overall Sentiment: AGENT=-0.1, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/01/6c7d9034-c552-491a-97de-835f6d9a4bca_20250501T13:13_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey, [PII], it's [PII] in customer care. How are you this morning?
[AGENT][POSITIVE] I'm doing well, [PII]. How are you?
[CUSTOMER][POSITIVE] I'm good it's early, girl.
[AGENT][NEUTRAL] It is, it is. I know the phone rang and I was like, oh, getting started early today, OK.
[CUSTOMER][NEUTRAL] I know it's too, it's too early for all this, OK, anyhow, um, I have an insured on the line. She has a question about a claim and so I can give you the policy and claim number when you're ready.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, go ahead.
[CUSTOMER][NEUTRAL] Uh, policy is 02527441.
[AGENT][NEUTRAL] Part one.
[CUSTOMER][NEUTRAL] Um, it's for part two, [PII].
[AGENT][NEUTRAL] Part 2, OK, and what's that claim that we're looking at?
[CUSTOMER][NEUTRAL] Yeah, and
[CUSTOMER][NEUTRAL] 359.
[CUSTOMER][NEUTRAL] 6099.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So claim was denied for EOB. I did check on base. I see an EOB now. I'm not a claims examiner so I could be missing something.
[CUSTOMER][NEGATIVE] Um, she's frustrated because she says they're always denied and she's like, I attached the EOB. I don't know what else you guys need.
[AGENT][NEGATIVE] Gotcha.
[CUSTOMER][POSITIVE] So if I'm missing something, please, yeah, enlighten so I can.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] You know I will, [PII], you know I will.
[AGENT][NEUTRAL] I'll be like, hang on, girl.
[CUSTOMER][NEUTRAL] Cause I will educate. I, no, yeah, no, I'll educate and be like, hey, you know, this, this and this is, you know.
[AGENT][NEUTRAL] Yeah, let me see what we have because it's.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Quite a date span, um, I mean that's nearly a month's worth of chemo, so let me see what we have and why they're requesting. I wonder if they put an EOB note. Did they put an EOB note on there by chance? Do you know?
[CUSTOMER][NEUTRAL] Um, let's see.
[AGENT][NEUTRAL] I mean, I don't, I don't think they did.
[CUSTOMER][NEUTRAL] I don't think so either.
[AGENT][NEUTRAL] But
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] OK, so we have the hospital stay and where they highlighted the chemo. So let me go in here and see.
[CUSTOMER][NEUTRAL] If I see
[AGENT][NEUTRAL] OK, and then there's 3:19.
[CUSTOMER][NEUTRAL] Yeah, because at first I just saw 319, but then I was like, oh I saw February and I was like, OK.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] So this, hang on, let me, let me finish looking because I don't, I'm only on like page 10 so I don't wanna be like this looks like without like really looking and determining what's going on here, OK.
[CUSTOMER][POSITIVE] No, no worries.
[CUSTOMER][NEUTRAL] Uh,
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So, 319 labs.
[AGENT][NEUTRAL] Drugs, drugs. Oh, you know what? Let's do this.
[AGENT][NEUTRAL] I need to see how much those two things cost. OK, so for 227.
[AGENT][NEUTRAL] We had a cost of 33,060.
[AGENT][NEUTRAL] And then for 3:19, so it's not actually a huge date span it's just two different dates and they put it in there as a date span which is fine. It can just be a little misleading sometimes. OK, so 4:39 20. Alright, now let's go to these EOBs attached because that's gonna be the kicker is associating those calls with because the thing is is that a lot of times on the EOBs they don't actually put the name like they do.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] On the bill and then you have to be like OK, I have to associate this cost with this charge right so I see 33,060.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] It looks like.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] It looks like there wasn't anything paid. Let me see if there's any remark codes.
[AGENT][NEUTRAL] Um, you pay $0. Here's the breakdown.
[AGENT][NEUTRAL] Hospital charges, your discounts due to your hospital and then what anthem paid, OK.
[AGENT][NEUTRAL] So hospital costs for that one were 3.
[AGENT][NEGATIVE] Uh, due to your hospital's 360, Anthem paid nothing.
[AGENT][NEUTRAL] Co-pay, deductible, co-insurances services not allowed also nothing.
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] You don't pay the your discount amount. This is the benefit to using doctors facilities in our plans.
[AGENT][NEUTRAL] I mean it looks like Anthem paid them.
[AGENT][NEUTRAL] What all the allowed amounts, it just isn't listed right there, um.
[AGENT][NEUTRAL] So I see that I'm gonna.
[AGENT][NEUTRAL] What
[AGENT][NEUTRAL] Let me see where this is at.
[AGENT][NEUTRAL] Because I see that it's denied, but it looks like it.
[AGENT][NEUTRAL] May it hasn't been completed out of the system so I'm trying to.
[AGENT][NEUTRAL] It's done yesterday.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] But it wasn't completed out of the system, which is unusual.
[AGENT][NEUTRAL] OK, um, that could have just been an error by the examiner, um.
[AGENT][NEUTRAL] OK, so I'm going to actually highlight this.
[AGENT][NEUTRAL] Because I'm not.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] Truthfully this may be something, no, that was the wrong call oops.
[AGENT][NEGATIVE] Wrong, [PII].
[CUSTOMER][NEUTRAL] This may have been a, a boo boo on.
[AGENT][NEUTRAL] It may have been the thing is is that so what we, what we do when we're looking at these for cancer policies is when we're looking at actual charges, which is what this policy is looking at, um, we look at what your insurance paid.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And what your responsibility is and then typically those two numbers combined are what your actual charges are like we don't look at that the charge amount because that would be looking at build charges and there's a.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Difference when we're looking at cancer policies because some go by build and some go by actual charges so the actual charges are after all the discounts and write offs and whatever what they paid versus what you owe is what you like what we're gonna pay. They have the allowed amount but they're not showing that they paid anything and they're not showing that.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] The insured owes anything which is probably even there is an EOB she's not, she's not wrong about that. There is an EOB um what I'm guessing and I'm not 100% on this, um, I would have to speak to the examiner or maybe even another auditor is they.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Like they don't, um.
[AGENT][NEUTRAL] They're not being specific. Like it's not broken down into what.
[AGENT][NEUTRAL] Maybe actually owed and so that's where it's difficult for the examiner so I don't think it's necessarily that we need an EOB but truthfully I'm not sure what we would request in its place. Um, let me finish looking because I'm on page 22 now so I'm about done because maybe there was a better breakdown. I'm not sure it looks like I'm on 319 now.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So 4:39.
[AGENT][NEGATIVE] 20 it it did the same thing like the charges there it says drugs which we know based on the other bills submitted that that is the chemo that we're looking at they have what they allowed but they're not showing that they paid anything they're not showing that the insured owes anything.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And so it's one of those things where it's like yes there is an EOB attached but it's not giving us the information that we need so I don't know that it's that another EOB is needed um.
[AGENT][NEUTRAL] That one's tough because they're, they're not, it, it's so difficult because they're
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEGATIVE] What should we do? because she's like, yeah, because she's frustrated, which I get because she's like I feel like every time I file one, you know, and I, yeah, I need to go back and let her know.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah, so let her know that um that it's gonna be reviewed we'll give her a call before the end of the day it may even be within the next hour I'm not sure with what needs to happen because it could be that based on what we have we can go back and be like OK they allowed this amount.
[AGENT][NEUTRAL] Or it may be, well they're not showing that they paid anything so if they did we need something showing from your insurance company that they paid towards this specific charge. I'm not sure um because with it being based on actual charges if there are no actual charges.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Then I'm pretty sure there's a remark code out there that says that no actual charges like were incurred but at the same time it looks like it's like that on every single charge but then it shows that they paid like a little over $3400 for this data service but that's strictly for the treatment room so it's it's really confusing you know on what's going on here. I, I'm not sure honestly.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. If she's like,
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, yeah, I told her we could call her back and she was like, well, nobody ever calls me back so um if she.
[AGENT][POSITIVE] I promise I will. What's her number? I will call her personally.
[CUSTOMER][NEUTRAL] Um, her number is [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, so I'm going to discuss this possibly with another auditor maybe even with the supervisor and just be like this is what was done.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] But we have an EOB.
[AGENT][NEUTRAL] The issue is that the EOB doesn't indicate actual charges, so do we have an issue of an incorrect remark code being used or do we have an issue of needing more information and maybe an EOB note needed to be included or something like that? Like I feel like more information is needed in some form. I just am not sure because this this is very rare truthfully for us to see where they pay.
[AGENT][NEUTRAL] Everything they're gonna pay on one line and then they don't pay they allow it they allow money on the other ones but they don't pay anything and they don't put anything to the insured. It's a very unusual situation. I don't know that I've seen many, if any, like this, so I am gonna have to kind of reach out and be like, hey, this is weird. What do we need to do in this situation? And then I will call her back. I don't know when that will be. I don't want to tell her, give me an hour because I don't, I don't know.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, but I will call her today because I'm not in the office tomorrow and I don't want her to go without a phone call, so I will call her today.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, alright, I will go back and let her know thank you.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Perfect and you can give her my name to say [PII] from claims is calling you back that way when I say hey this is [PII] from APL she knows, OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK. All right. I will, [PII]. Thank you.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] All right. You're welcome.
[CUSTOMER][NEUTRAL] Bye.
[AGENT][NEUTRAL] Bye.