AccountId: 011433970860
ContactId: 7da406f3-5829-49c9-bc72-10984fa8c0c0
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1130339 ms
Total Talk Time (AGENT): 472369 ms
Total Talk Time (CUSTOMER): 621306 ms
Interruptions: 7
Overall Sentiment: AGENT=1, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/15/7da406f3-5829-49c9-bc72-10984fa8c0c0_20250515T16:44_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Good morning [PII] it's [PII]. We talked via email um you, I think, uh, [PII] had reached out to you and given me your name and you gave me your, uh, your phone number and your, uh, extension and said that this today and yesterday would be the times you would be there. So anyway, I have called to ask you some questions about some claims. So do you want the policy number first?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yep, uh, yeah, let's start with that.
[CUSTOMER][NEUTRAL] OK, it's 78413.
[AGENT][NEUTRAL] OK, and name and date of birth?
[CUSTOMER][NEUTRAL] [PII] and date of birth is [PII].
[AGENT][POSITIVE] Alright thanks you.
[CUSTOMER][NEUTRAL] Wait [PII].
[AGENT][POSITIVE] Got it. All right, give me one moment to get that pulled up and I will be glad to assist.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] One second.
[AGENT][NEUTRAL] I was gonna reach out to you um before the end of day today I came in and I was like, I haven't heard from [PII].
[CUSTOMER][NEUTRAL] Uh, we've had a lot of things happening and I thought, and I have limited time today and I thought I've got to call so um I'm calling I figured we get started and then I'll probably call again next week.
[AGENT][NEUTRAL] Let's see.
[AGENT][POSITIVE] OK, no problem.
[CUSTOMER][NEUTRAL] Are you off on Fridays?
[AGENT][NEUTRAL] I am actually off on tomorrow. It's not every Friday, but this Friday, yes, I'm off.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] It's a graduation season, so, yeah, it's pulling me out of the office a lot.
[CUSTOMER][POSITIVE] Good for you.
[CUSTOMER][NEUTRAL] Yes it is.
[CUSTOMER][POSITIVE] Oh my goodness, I've done the same.
[AGENT][NEUTRAL] Mhm. All right, so I have it up. Let's see uh what questions did you have specifically?
[CUSTOMER][NEUTRAL] OK, well I thought we would start with that last um EOB that we got it was dated [PII] and I can give you the reference number.
[AGENT][NEUTRAL] OK, what is it?
[CUSTOMER][NEUTRAL] Um, it is 00078413.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] Mm, I don't see that. Do you have the date of service?
[CUSTOMER][NEUTRAL] Um, well, it's, there's a bunch of data dates of service, um.
[AGENT][NEUTRAL] It's a bunch. How about the claim number?
[CUSTOMER][NEUTRAL] Uh, claim number is 3586788.
[AGENT][NEUTRAL] All right, got it.
[AGENT][NEUTRAL] OK, let's see what happened here.
[AGENT][NEUTRAL] All right, I show a few duplicate charges and we're asking, go ahead.
[CUSTOMER][NEUTRAL] And I've got, I've got questions about that too. Do you, do you wanna start at the top and let's move down because I think the first one is it the duplicate? Let's see, OK, OK, that first one that says the services from [PII] and [PII] non-covered services.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEGATIVE] Uh, will you tell me what you're showing that to be, uh, you know, this client, I stepped into this position after the fact and there was not very many bread crumbs that were left for me. So, um, it kind of hampered me in researching why things were denied.
[CUSTOMER][NEUTRAL] So do you have something that that shows exactly what that is?
[AGENT][NEUTRAL] Understood.
[AGENT][NEUTRAL] Absolutely, yeah. So, um, and just uh.
[AGENT][NEUTRAL] Overall, um, just to help with the thought processing of the claims. Um, anytime you see a non-covered and it does not specify as far as the procedure or if it's a date span like we're looking at now, that's, that's typically the usual services that are not covered. In this case, it's uh office visit.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] So we address anything that's on the bills, uh, itemized billing that we received, and so there were some office visits that were submitted uh starting [PII]. So those were just lumped into you should have a page two of the explanation of benefits that gives you the description, yeah, so, um.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] And it says office now I have another question. What defines an office visit because he, he went to um.
[CUSTOMER][NEUTRAL] Because this was an MD Anderson, uh, doctor, and he went because of the cancer. So what defines an office visit?
[AGENT][NEUTRAL] Any um services billed for the actual visit itself. No matter what was performed during that visit, you know, if procedures were taking place, the charges for the actual doctor's visit is not covered.
[CUSTOMER][NEUTRAL] So it doesn't matter that he went to see a cancer doctor that was, I guess, getting him on a protocol to fight the cancer. Uh, the, the initial, so is the office visit the initial visit before they do the treatment? Is that what?
[AGENT][NEUTRAL] Yeah, an office visit could be billed on the same day that the treatment is performed. So while that treatment may be covered, this policy would not cover the actual visit. So, when the doctor's, uh, bill.
[CUSTOMER][NEUTRAL] OK, so never ever ever is an office visit covered in on this OK, alright, so no office visits are covered.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] No payment for the visit, but like I said, if there's any covered services or treatment received during that visit, then that would be considered, but not the visit itself.
[CUSTOMER][NEUTRAL] OK, OK, let me make a note here so but if treatment is on the same day.
[CUSTOMER][NEUTRAL] So when they see a doctor, that is not covered at all. So it's just the treatments, OK, if, but if treatment on the same day, they cover that.
[AGENT][NEGATIVE] Not at all.
[CUSTOMER][NEUTRAL] That is covered.
[CUSTOMER][NEUTRAL] OK, well that clears things up on that issue um so I can go back I guess on our things that I submitted and pull out.
[CUSTOMER][NEUTRAL] Those
[CUSTOMER][NEUTRAL] Doctor visits from [PII] [PII]. OK. OK. All right, so then.
[CUSTOMER][NEUTRAL] Number 2.
[CUSTOMER][NEUTRAL] OK, and it says we've got duplicate claims, um, but what if they weren't paid and uh and they were resubmitted I guess to to make them more clear how do you how what do y'all mean by a duplicate claim? Do you mean because we haven't been paid much at all so I think.
[CUSTOMER][NEUTRAL] The what they're saying is duplicate. Let me pull that other thing. Hold on a second before I start running my mouth. Hold on one second, OK? OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Actually, I think, uh, OK, that lab and diagnosis, the biopsy on [PII], was that paid?
[AGENT][NEUTRAL] It looks like we're requesting the explanation of benefits.
[CUSTOMER][NEUTRAL] I wonder if that
[CUSTOMER][NEUTRAL] On that first thing but it says it was.
[CUSTOMER][NEUTRAL] It says it was duplicate or previous submitted but it it looks like it may have been paid um can I give you the reference where you can look and see if it's the same?
[AGENT][NEUTRAL] I can check it uh for the biopsy.
[CUSTOMER][NEUTRAL] Thing
[CUSTOMER][NEUTRAL] OK,
[CUSTOMER][NEUTRAL] Well, that lab and yes so it looks like.
[AGENT][NEUTRAL] On 1014.
[CUSTOMER][NEUTRAL] 1014, it looks like it was paid.
[CUSTOMER][NEUTRAL] Possibly um on the check date was [PII], the let's see, the policy number I leave you claim number is 355.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] 0441. OK, so that was paid there that particular.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Charge, right? OK, alright, so let me put a reference to that so that was paid.
[AGENT][NEUTRAL] So the biopsy was paid, but we, um, let's see.
[AGENT][NEUTRAL] Yeah, that was paid back in January.
[CUSTOMER][NEUTRAL] OK, I got that um and then.
[CUSTOMER][NEUTRAL] A non-covered service on [PII], can you tell me what that would be? Um, [PII]:25 that next chart says noncovered service.
[CUSTOMER][NEUTRAL] And it said procedure, the procedure code is 21079.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah, that looks like um.
[CUSTOMER][NEUTRAL] What is that?
[AGENT][NEUTRAL] Uh, type of DME durable medical equipment or prosthesis, that's not covered under the policy.
[CUSTOMER][POSITIVE] OK, so this is durable.
[CUSTOMER][NEUTRAL] Medical
[CUSTOMER][NEUTRAL] Equipment
[CUSTOMER][NEUTRAL] Is not covered, so that'll help me find whatever was submitted for that claim.
[CUSTOMER][NEUTRAL] OK, and then that next one from [PII] to [PII] transportation automobile not covered so what.
[CUSTOMER][NEUTRAL] What was that not covered for?
[AGENT][NEUTRAL] So for 11:14.
[AGENT][NEUTRAL] Transportation was paid, I'm sorry, for 10:14, the transportation was paid anytime there's a covered surgery or chemotherapy, immunotherapy, radiation therapy received, and it is more than 50 miles away from the home address, there's a transportation benefit.
[CUSTOMER][NEUTRAL] No 1014.
[AGENT][NEUTRAL] So the surgery for [PII], which was that biopsy that was paid. We've also paid the
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] Yes, I see that
[CUSTOMER][NEUTRAL] I see that but then it's got unless it's a typo, it has 10:14 to 11:25. I see where the 1014 was paid. It was on that same check that other thing we were just talking about was on, but it goes to [PII], so what else is in there?
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] So on the um remarks remarks for the transportation, that date span on [PII], it's showing as a duplicate because it was paid. And the additional dates, it's because on previous claims, those were denied as no covered treatment received for that date of service. So, um,
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Basically, what you're seeing, and I can understand the um confusion there because this claim that we've received, the, the most recent claim that was processed, it entailed um multiple days of service that had previously been addressed in the past. So once we, if you see a duplicate, it doesn't um.
[AGENT][NEUTRAL] Necessarily mean that benefits paid. It means that we've received these um dates of service or charges and we've uh supplied the answer or a payment and so when we see it again, it's uh processed as a duplicate as we've already um given a claim decision on those services, um.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK, that makes sense to me um um so.
[CUSTOMER][NEUTRAL] So when y'all have duplicate charge it's either been paid.
[CUSTOMER][NEUTRAL] Or it's been addressed already is what you're saying so OK um.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] All right, so.
[CUSTOMER][NEUTRAL] The next one, which has a number 3 remark, what is an explanation of update? What does that mean?
[AGENT][NEUTRAL] Let's see what um data service is this.
[CUSTOMER][NEUTRAL] It is, um, the first one is 10:15.
[CUSTOMER][POSITIVE] Yeah, 10:15 laboratory and positive diagnosis.
[AGENT][NEUTRAL] OK, so for that one we requested the primary explanation of benefits.
[CUSTOMER][NEUTRAL] So you need an EOB primary, the primary insurance, is that what you mean?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, need primary insurance EOB for all number threes.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] OK, now
[CUSTOMER][POSITIVE] Hoping I can figure out what those dates are. I think I can.
[CUSTOMER][NEUTRAL] OK and then what's the best way to um submit it? I know you go online and you just upload stuff but what I did was put a cover sheet so it would help me with bread crumbs when I have to go back and look at it and go oh yeah I know why I did that. Does that help y'all at all or I I don't even guess it matters? OK.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] It, it does, um, because it can be a lot of information, so any additional information that you can provide, it absolutely helps in the processing of the claims.
[CUSTOMER][NEUTRAL] Yes, and I mean the way I look at it is what if you're gone that day and you have a new person there?
[AGENT][POSITIVE] Yeah, absolutely. Uh-huh.
[CUSTOMER][NEUTRAL] You know they can they can just follow bread crumbs. OK, well what I'm gonna do is I'm gonna work on this and then I'm gonna dig um on that one the the EOB before this and it's just it, it's hard to read this stuff because it doesn't give much of a description to match up with everything that was submitted prior to me getting here so um.
[AGENT][NEUTRAL] Let me take a look at the claims history because I, I can say this is um.
[CUSTOMER][NEUTRAL] Ah
[AGENT][NEUTRAL] Pretty old claim. It claim affect um the policy, the policy effective date is [PII]. So, um, of course, the, the verbiage and um specifics of the claim, uh, of the policy, it's
[AGENT][NEUTRAL] It's, it's pretty dated, so, uh.
[CUSTOMER][NEUTRAL] And it's changed, it sounds like because he, his wife,
[AGENT][POSITIVE] Yes, absolutely.
[CUSTOMER][NEGATIVE] They covered so much of her cancer services, and he thought it was gonna be the same with his, but it's not.
[AGENT][NEUTRAL] And I did, um, based on the email that I had, and I, I compared uh the payments and the differences, why, because there's not much that we did not pay that is covered on the policy for Mr. [PII]. The difference was Mrs. [PII] received chemotherapy, which is one of the large benefit payments because it's expensive.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] Um, service. So, from what I can see in the claim's history, we have a biopsy here. So it's, it's
[AGENT][NEUTRAL] It's a bunch of, I don't want to say small benefits, but again, there's a big difference because that chemo pays.
[AGENT][NEUTRAL] Uh, much more. Yeah.
[CUSTOMER][NEUTRAL] OK, well, he couldn't understand and so uh that makes and I, I printed the policy out and I've kind of looked through it but oh my gosh, when you're not, that's not your thing when you're not a policy reader.
[AGENT][NEUTRAL] Mhm. That's a lot.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] So much. Well, that helps.
[AGENT][NEUTRAL] But that's the difference we've paid uh the benefits.
[CUSTOMER][NEUTRAL] OK, so when, when.
[AGENT][NEUTRAL] Anytime there's a surgery or biopsy, we pay that surgery and biopsy plus the um a uh benefit for the facility on that date of service plus transportation. I don't see much where we have um not paid the benefits, but again, that's the difference, that chemo would
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, so yeah, that thank you for doing that and I have a question when I submit transportation because I I did I did see where it will cover their transportation um because they are like I think it's 4 hours away, but you do you need like the map like to show that where they live versus where the where [PII] is versus where they live and then you.
[AGENT][NEGATIVE] No, not at all.
[AGENT][NEUTRAL] Only the, yeah, only the physical address um where the services were performed. And just keep in mind that, it's only when certain uh treatment or procedures are received that that transportation would be considered. So if it's just for a doctor's visit, we wouldn't consider transportation.
[CUSTOMER][NEUTRAL] OK, because y'all can figure that out.
[CUSTOMER][NEUTRAL] OK, only.
[CUSTOMER][NEUTRAL] OK, it's only under the umbrella when there's a service covered.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Does travel kick in? OK, that makes sense. OK, well if you don't mind holding my hand through this process.
[AGENT][NEGATIVE] Yeah. Nope, not at all.
[CUSTOMER][POSITIVE] Um, well, I, I can, that way I can better explain to them when I present what's what's not covered versus the corrections that we have to make and send in for coverage services. um, thank you so much, [PII]. I'm so glad I found you because.
[CUSTOMER][POSITIVE] Um, it's, it's like hit in the dark or, or trying to do something in the dark. All right, thank you so much and I'll be back in touch. Are you working, are you walking, walking? Are you working all next week?
[AGENT][POSITIVE] I definitely understand.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] I'm absolutely here.
[AGENT][POSITIVE] All next week I'll be in the office. Uh, feel free to give me a call or shoot, shoot an email. If you call and I don't answer, I'll probably, it's probably a time I've stepped away from my desk, but, um, an email and um and or call, and I'll respond as soon as I can.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] OK, if I can get it out of my mouth, out of my brain into an email where you would understand it, I will definitely send an email.
[AGENT][POSITIVE] Don't hesitate to pick up the phone and give me a call, no problem.
[CUSTOMER][POSITIVE] All right. Thank you so much. You have a good weekend and a good graduation. OK, bye-bye.
[AGENT][POSITIVE] All right, [PII]. Thank you. You as well. Thank you. Bye-bye.