AccountId: 011433970860
ContactId: 7430def5-c925-47e5-ba5b-2e236c442bfa
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1139729 ms
Total Talk Time (AGENT): 298025 ms
Total Talk Time (CUSTOMER): 467137 ms
Interruptions: 0
Overall Sentiment: AGENT=0.4, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/18/7430def5-c925-47e5-ba5b-2e236c442bfa_20250618T16:06_UTC.wav
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[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Good morning. Thank you for calling APL. This is [PII]. May I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII]. How are you?
[AGENT][NEUTRAL] I'm doing fine. How are you?
[CUSTOMER][NEUTRAL] I am good. I, um, have some questions. I had sent in a claim. It's kind of been going on for the last 2+ years trying to get some reimbursement, and I have my insurance representative with me as well and just kind of wanting to get some clarifications on some things.
[AGENT][NEUTRAL] OK. Do you have a phone number I can get in case we get disconnected, I can call you back?
[CUSTOMER][NEUTRAL] I'll give you my cell phone number. It's [PII].
[AGENT][NEUTRAL] And do you have your policy number?
[CUSTOMER][NEUTRAL] Um, I have my card, but let me.
[CUSTOMER][NEUTRAL] Uh, policy number 01834915.
[AGENT][NEUTRAL] Thank you, hold on one moment please.
[AGENT][NEUTRAL] And can I verify your date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And can I verify your address and email address, please?
[CUSTOMER][NEUTRAL] Um, I'm trying to log into the system and it's not letting me. I feel like I have my personal email logged in with you. It's [PII].
[AGENT][NEUTRAL] Yes, that's the one we have. And your mailing address?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you, Ms. [PII], and you were calling about some claims that you had sent in?
[CUSTOMER][NEUTRAL] Yes, I have sent in several different ones um on behalf of uh
[CUSTOMER][NEUTRAL] A claim that I had back in, I think [PII], I believe, so maybe it's been three years.
[AGENT][NEUTRAL] OK, I can hear
[AGENT][NEUTRAL] I can help you with that. What data service was it for?
[CUSTOMER][NEUTRAL] But it's kind of
[CUSTOMER][NEUTRAL] Um, I feel like I had my accident on [PII].
[CUSTOMER][NEUTRAL] And then from then I've sent several different claims um for Dr. [PII] or it might be under immediate smiles.
[AGENT][NEUTRAL] OK, did you say this was for [PII]?
[CUSTOMER][NEUTRAL] I believe it was and I've been going back and forth with you guys since then along with Blue Cross and Blue Shield. It could have been 23, but I feel like it was 22.
[AGENT][NEUTRAL] It must be 23 because I don't see anything for 22.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, for 84 of 23.
[AGENT][NEUTRAL] We received.
[AGENT][NEUTRAL] Hold on just a moment. Let me pull up the
[AGENT][NEUTRAL] Claim
[CUSTOMER][POSITIVE] Yeah, 84 of 23 that's that's right.
[CUSTOMER][POSITIVE] Well it makes me feel better.
[AGENT][NEUTRAL] OK, we have one for immediate smiles for 84 of 23.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Hold on one moment. We, because we asked for the EOB and then we got an EOB.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And it was paid in full for that on that one.
[CUSTOMER][NEUTRAL] Paid in full what way can you explain that?
[AGENT][NEUTRAL] Paid in full means that your major medical paid it in full. We don't have anything left to pay.
[CUSTOMER][NEGATIVE] It did not paid in full. I paid out of pocket.
[CUSTOMER][NEUTRAL] The full
[AGENT][NEUTRAL] OK, did they apply anything to your deductible copay or co-insurance on your major medical?
[CUSTOMER][NEUTRAL] Well, they did, but because it was out of network they only paid the net out of network portion.
[AGENT][NEUTRAL] OK, the only thing this insurance picks up if they applied anything to your deductible copay or co-insurance. So if they did, we need that exclamation of benefits that shows what was applied to your deductible copay or coinsurance.
[CUSTOMER][NEUTRAL] OK, now I'm the agent and I'm, I'm confused.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Because I thought this coverage was in the event that they had a claim.
[CUSTOMER][NEUTRAL] Through carrier Blue Cross Blue Shield.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] And they would pay up to a fixed amount I believe in this case is $1000.
[AGENT][NEUTRAL] Yeah, but it coordinates with the primary insurance, whatever the primary applies to their deductible, co-pay, or co-insurance only.
[CUSTOMER][NEUTRAL] Well.
[CUSTOMER][NEUTRAL] Can you say that one more time? You kind of.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] It only pays if your Blue Cross applied anything to your deductible copay or co-insurance.
[AGENT][NEUTRAL] That's the only 3 things that we pick up deductible, co-pay, or coinsurance.
[CUSTOMER][NEUTRAL] OK, so if it's a claim.
[CUSTOMER][NEUTRAL] And that claim had something paid by Blue Cross Blue Shield.
[CUSTOMER][NEUTRAL] Whatever remainder would be co-insurance.
[AGENT][NEUTRAL] So we, if it was something to co-insurance, then we need an EOB stating that.
[CUSTOMER][NEUTRAL] Out of pocket.
[AGENT][NEUTRAL] Because the ones we received.
[CUSTOMER][NEUTRAL] OK, um
[AGENT][NEUTRAL] Uh, it's showing that they paid it in full.
[CUSTOMER][NEUTRAL] OK, ma'am, I, I've personally sent and [PII] has personally sent EOB showing the claim and how much Blue Cross Blue Shield pay.
[CUSTOMER][NEGATIVE] They didn't pay nowhere near the full cost because it was out of network.
[CUSTOMER][NEGATIVE] It was an emergency. She broke her jaw, had to go somewhere quickly so they could fix her and.
[CUSTOMER][NEUTRAL] Primarily save her life.
[AGENT][NEUTRAL] Right, now I can pull up each claim and look at it.
[AGENT][NEUTRAL] With you, but um.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Each claim on your end or each claim that we've sent you?
[AGENT][NEUTRAL] Each claim that I have in the system.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Was that something other than what we. Yeah, it was just the EOB from Blue Cross and Blue Shield. We're not covered 4,01671 and they paid 60319.
[CUSTOMER][NEUTRAL] OK, so it'll stay there because she's gonna find that same thing. Mhm. I was trying to find, you know, how I got from Blue Cross and Blue Shield. It was like a front and back Excel that it showed everything that I was trying to I was trying to find that.
[CUSTOMER][NEUTRAL] I don't have it here anymore, you know, I printed it out.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Hold on one moment I'm looking only one I see on this is we just have the claim we don't even have an EOB on this one. Hold on just a moment let me pull up the other one.
[CUSTOMER][NEUTRAL] We just
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Would it, would it, would it be helpful?
[CUSTOMER][NEUTRAL] If we sent you what we have on this end so you can look at it.
[AGENT][NEUTRAL] You can.
[AGENT][NEUTRAL] But if it doesn't have anything that's applied to the deductible copay or co-insurance, we're not going to be able to do anything with it.
[CUSTOMER][NEUTRAL] OK, I'm, I'm still confused if you have a claim for $4000.
[CUSTOMER][NEUTRAL] And the insurance company paid $600.
[CUSTOMER][NEUTRAL] Then where would the rest of it go?
[CUSTOMER][NEUTRAL] Other than coinsurance.
[CUSTOMER][NEUTRAL] Deductible or whatever.
[CUSTOMER][NEUTRAL] That's not gonna go to deductible because it was an emergency situation.
[CUSTOMER][NEUTRAL] So it would go to my.
[AGENT][NEUTRAL] Right, but see, on the, on the EOB we can't go by what they paid or anything like that. We're looking for something that was applied to the deductible, co-pay or co-insurance.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And this EOB that I'm looking at doesn't show that.
[AGENT][NEGATIVE] It only shows me amount billed, what was not covered, and what was covered. It doesn't have the deductible copay or co-insurance on it.
[CUSTOMER][NEUTRAL] OK, um, are you looking at the one.
[CUSTOMER][NEUTRAL] That's 4,061,990.
[AGENT][NEUTRAL] Yes, sir.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And is it dated? I'm looking for.
[CUSTOMER][NEUTRAL] The
[CUSTOMER][NEUTRAL] Uh, so that's the day of the occurrence.
[CUSTOMER][NEUTRAL] No, that would be the date of it. My current was 23. OK. Uh, does it show 4/25 of 24 at the very top?
[CUSTOMER][NEUTRAL] On the right on the right hand side under Griffith Family Bank.
[AGENT][NEUTRAL] Yes, 4 25 24, yes.
[CUSTOMER][NEUTRAL] OK, so we're we're on the same page.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] For the 46 and they paid 60319.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] So help me understand where did the rest of the 4600 go.
[CUSTOMER][NEUTRAL] If it didn't go.
[CUSTOMER][NEUTRAL] To co-insurance.
[AGENT][NEUTRAL] That I'm not sure that's why we have to have something in writing that has, it has to have a column on this EOB that has deductible, co-pay or co-insurance.
[AGENT][NEUTRAL] So there should be another EOB.
[AGENT][NEUTRAL] Showing
[AGENT][NEUTRAL] What was applied to those three columns if nothing was applied to the deductible copay or coinsurance.
[AGENT][NEUTRAL] Then we wouldn't cover anything.
[CUSTOMER][NEGATIVE] So if I had to come up with 4000 out of pocket for a medical emergency, then you're saying if they did not apply anything to the deductible, then I, even though you guys are gap insurance, I am not going to be reimbursed in any way.
[AGENT][NEUTRAL] Right, it has to have something applied to the deductible copay or co-insurance.
[AGENT][NEUTRAL] So you can call Blue Cross and ask them.
[AGENT][NEUTRAL] If you can get a copy of your EOB or if there was anything that was applied to the deductible copay or co-insurance.
[CUSTOMER][NEUTRAL] Uh, does the policy.
[CUSTOMER][NEUTRAL] With APL.
[CUSTOMER][NEUTRAL] Have an arbitrator clause in it.
[AGENT][NEGATIVE] That I'm not sure I could have someone call you back.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] You need my phone number?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh
[AGENT][POSITIVE] I can get my supervisor to call you all back. Is there anything else I can help you with?
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] OK, now did you get my name?
[AGENT][NEUTRAL] OK, and I'm sorry, what was your name?
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] No, [PII]
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, now I'm, I'm, I'm looking at a document.
[CUSTOMER][NEUTRAL] From Blue Cross Blue Shield.
[CUSTOMER][NEUTRAL] That shows $603.19 was applied towards deductible.
[AGENT][NEUTRAL] OK, if, if that's what you have, then you can send it to us and we can look at it.
[AGENT][NEUTRAL] If it's showing it was applied to the deductible.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, um, can you reset my password? I've been trying to log in and it won't let me.
[AGENT][NEUTRAL] I can
[CUSTOMER][NEUTRAL] I've been using my email.
[AGENT][POSITIVE] I can get someone to call you back that can is able to do that.
[CUSTOMER][POSITIVE] OK, that would be great.
[CUSTOMER][NEUTRAL] OK now um.
[CUSTOMER][NEUTRAL] Where what fax number do we send this document to for you to review?
[AGENT][NEUTRAL] It would be 877.
[CUSTOMER][NEUTRAL] 7.
[AGENT][NEUTRAL] 365.
[AGENT][NEUTRAL] 942 3.
[CUSTOMER][NEUTRAL] OK, and whose attention do I need to put it to and a reference?
[AGENT][NEUTRAL] It would be claims department.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And is there something that can I can send this information that can attach to whatever else you have on file so they know.
[CUSTOMER][NEUTRAL] What it goes with.
[AGENT][NEUTRAL] You
[AGENT][NEUTRAL] You can just put your policy number on it.
[CUSTOMER][NEUTRAL] OK. OK.
[AGENT][NEUTRAL] And we have all the claims that were sent in, so they'll just review all of it.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And you are gonna have someone call me on the arbitration.
[AGENT][POSITIVE] Yes, I will.
[CUSTOMER][POSITIVE] Thank you so much.
[AGENT][POSITIVE] You're welcome. Is there anything else I can help you with?
[CUSTOMER][POSITIVE] Thank you. Have a
[CUSTOMER][POSITIVE] Uh, not today, thank you.
[AGENT][POSITIVE] Thank you, Ms. [PII] and Mr. No for calling APL. You have a good day.
[CUSTOMER][NEUTRAL] Bye bye.
[AGENT][NEUTRAL] Uh-huh, bye-bye.