AccountId: 011433970860
ContactId: 80fe9ce1-d700-4200-8d39-afa8eacf583a
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1438400 ms
Total Talk Time (AGENT): 666768 ms
Total Talk Time (CUSTOMER): 393206 ms
Interruptions: 1
Overall Sentiment: AGENT=0.6, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/12/80fe9ce1-d700-4200-8d39-afa8eacf583a_20250212T16:28_UTC.wav
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[AGENT][NEUTRAL] And thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII], and I'm calling for help understanding a few claims that I've recently processed.
[AGENT][NEUTRAL] OK, you said your name is [PII] and I'm so sorry, what was your last name?
[CUSTOMER][NEUTRAL] No, the first name is [PII] and the last name is [PII], [PII].
[AGENT][NEUTRAL] OK, Ms. [PII] let's say you have a question regarding
[AGENT][NEUTRAL] A couple of claims that have recently been processed for you. Is that correct?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Correct.
[AGENT][POSITIVE] Yes, ma'am. I can help you with that. And Ms. [PII], what is a good callback number for you?
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you and your policy number please?
[CUSTOMER][NEUTRAL] Policy number is 01422256.
[AGENT][NEUTRAL] OK, thank you, so one moment please while I get your information pulled up.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] OK, so I will need to verify several things with you first for security purposes and also any information that I do provide for you today and will be a verification of benefits and not a guarantee of payment. So first off, if you could verify the subscriber's name and date of birth and then your date of birth please.
[CUSTOMER][NEUTRAL] Uh, [PII], [PII], and my date of birth is [PII].
[AGENT][POSITIVE] OK, thank you also your home mailing address.
[CUSTOMER][NEUTRAL] It's [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, thank you. And then um the last four of Mr. [PII]'s Social Security number.
[CUSTOMER][NEUTRAL] Hold on a second.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK, thank you very much.
[AGENT][NEUTRAL] OK, so what is the, do you have the claim numbers that you have questions on, [PII]? OK.
[CUSTOMER][NEUTRAL] Yeah, I, I'm not. I think that some of my claims.
[CUSTOMER][NEUTRAL] We bundled.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] Right now the one I'm looking at is 3561393.
[AGENT][NEUTRAL] OK, so one moment. So yes, ma'am, I can see that one was just recently processed on 210.
[AGENT][NEGATIVE] OK. Mm. And I can see that it was denied.
[AGENT][NEUTRAL] Let me look at your dates of service. Was this for an inpatient admission?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes, I went in through, I went into the emergency room.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So give me just one moment. OK, so the remarks for the denial on a couple of the codes state that your primary insurance provided full benefits, so there were no benefits payable. Um, the other.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] What do you mean?
[CUSTOMER][NEUTRAL] OK, wait, because this is what I'm not understanding. I read it so I know what it says, but.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] What about, so if the insurance provided full benefits, that means there would be no outstanding amounts due.
[AGENT][NEGATIVE] There would be no benefits payable by this policy.
[CUSTOMER][NEUTRAL] But that's not
[AGENT][NEUTRAL] This policy only helps with co-pays, deductibles, and co-insurance amounts of covered services. [PII]. I can see that we also are in need of a diagnosis code.
[AGENT][NEUTRAL] For
[AGENT][NEUTRAL] The [PII], [PII], [PII], and [PII], and that information would be obtained from your provider.
[AGENT][NEUTRAL] You can get that from the hospital.
[CUSTOMER][NEUTRAL] OK. All right.
[CUSTOMER][NEUTRAL] Oh first with the Miami-Dade Fire Rescue.
[CUSTOMER][NEGATIVE] You guys don't pay for the
[CUSTOMER][NEUTRAL] For the portion that my insurance doesn't cover?
[AGENT][NEUTRAL] On which data service specifically are you inquiring about?
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Miami Dade Fire Rescue.
[AGENT][NEUTRAL] OK, so the
[AGENT][NEUTRAL] This is all for inpatient for this status for this particular claim number?
[CUSTOMER][NEUTRAL] OK, but that, that's not impatient. Miami-Dade Fire Rescue is the, the, the fire rescue from my house to the hospital.
[AGENT][NEUTRAL] OK, this shows on this particular claim though it's Baptist Hospital of Miami, a Doctor [PII], and a Doctor [PII]. It's on this claim number.
[CUSTOMER][NEUTRAL] No, I'm looking at the claim number that was just the actual benefits that I just pulled up from the website and then claim number 3561393.
[AGENT][POSITIVE] Mhm. That is correct, yes ma'am.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Two items are Miami-Dade Fire Rescue on the explanation of benefits.
[AGENT][NEUTRAL] Let me look at the explanation of benefits because that claim number.
[AGENT][NEUTRAL] That is not what I can, that's not what I see, so give me just one second.
[AGENT][NEUTRAL] It takes a moment for this information to load, [PII].
[AGENT][NEUTRAL] OK, so according to your explanation of benefits that was submitted with that claim for the Miami Dade Fire and Rescue, your share was $0.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK, I don't know where you got that because the invoice that I submitted says that my share was $336.66.
[AGENT][NEUTRAL] OK, I'm looking at the documents that were submitted to us for review.
[AGENT][NEUTRAL] That is on your primary insurance company's explanation of benefits.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Let me go back and tell you.
[CUSTOMER][NEUTRAL] When this was submitted.
[CUSTOMER][NEUTRAL] I have
[CUSTOMER][NEUTRAL] That it was submitted on.
[CUSTOMER][NEUTRAL] Uh, [PII].
[CUSTOMER][NEUTRAL] And my confirmation number was 0SC.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 932009
[AGENT][NEUTRAL] OK, so that's a different claim number in your portal than what you gave me. That's claim number 3562605 that was processed today.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um
[AGENT][NEUTRAL] I was looking at the claim number that you gave me that was uploaded on 23 with the explanation of benefits.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And that is what that shows for that.
[CUSTOMER][NEUTRAL] Hold on just a second.
[CUSTOMER][NEUTRAL] That I submitted on 23.
[AGENT][NEUTRAL] For the claim number you initially gave me?
[CUSTOMER][NEUTRAL] Yeah, I just, I, I, I think what happened is that a bunch of things got
[CUSTOMER][NEUTRAL] Because I'm looking at the claim that I submitted on on 23 again here on the.
[AGENT][NEUTRAL] 5 pages.
[CUSTOMER][NEUTRAL] On the
[CUSTOMER][NEUTRAL] And it's only showing me 3.
[CUSTOMER][NEUTRAL] It's showing me uh that I submitted explanation of benefits on 23 I submitted benefits for Baptist, for Baptist, and for Baptist.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] OK, it shows because there's a cover, there's cover sheets that come along. So there was a total on that was submitted.
[AGENT][NEUTRAL] Of 14 pages that we received.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] That was the initial, and on the very first page.
[AGENT][NEUTRAL] Of the Aetna explanation of benefits. That's what I was looking at where it shows about the Miami-Dade fire.
[CUSTOMER][NEUTRAL] But
[AGENT][NEUTRAL] That's where I was getting my information from.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] And did prior.
[CUSTOMER][NEUTRAL] Your share is $0 but I said OK, I, I see what you're looking at now, but I submitted the bill from Miami-Dade Fire.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And it shows a balance of 336 66.
[CUSTOMER][NEUTRAL] This was submitted on [PII].
[CUSTOMER][NEUTRAL] So I don't know where Aetna got that my share is on is $0.
[AGENT][NEUTRAL] OK, now I, I can transfer you or I can try and transfer you to an examiner who can look at the two sets of documents with you.
[AGENT][NEUTRAL] Ms. [PII], cause it does look like that the information that was received and processed what you most recently submitted, it appears to have been a duplicate according to what I can see.
[AGENT][NEUTRAL] But you're saying that is different information, is that correct?
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] OK, so let me look at the remark on the one that was just reviewed.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] That is what that is showing.
[AGENT][NEUTRAL] Um, that it appears to be a duplicate of previously submitted expenses. Again, this policy, it only helps with the co-pays, deductibles, and co-insurance amounts of covered services.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So the
[AGENT][NEUTRAL] According to the information we received your, let me, let me just double check one thing.
[AGENT][NEUTRAL] Yes, according to your explanation of benefits received from your primary insurance, there was nothing applied for the ambulance to those three categories.
[CUSTOMER][NEUTRAL] That I mean that's why I submitted the copy of the invoice or the statement that I received from um Miami Dade Fire rescue showing a balance of 336 66.
[AGENT][NEUTRAL] That is correct, but we have to go by what your primary insurance company.
[AGENT][NEUTRAL] It's not just your bill. Excuse me. It's
[AGENT][NEUTRAL] What is applied to each of those three categories.
[AGENT][NEUTRAL] And it doesn't appear that your primary insurance applied anything for your ambulance.
[CUSTOMER][NEUTRAL] So, so who pays that?
[AGENT][NEGATIVE] That would not be covered. I mean, you know, if they, if your primary insurance is not covering something or applying something to one of those three areas, there would not be anything for this policy.
[AGENT][NEUTRAL] To pay.
[CUSTOMER][NEUTRAL] OK, I, I, I don't, I'm not sure I understand that, but I, I guess I'll have to reach out to.
[CUSTOMER][NEGATIVE] To the insurance company and ask them why they zeroed out the balance on that and ask them for another explanation of benefits. I'm, I'm not sure how to proceed.
[AGENT][NEUTRAL] Yes ma'am, you can do that. And then as far as with our reviews.
[CUSTOMER][NEUTRAL] So I would
[AGENT][NEUTRAL] Um, I can see, so.
[AGENT][NEUTRAL] We're discussing, we're looking at the two separate claims. The second claim that you for the information you uploaded on the [PII].
[AGENT][NEUTRAL] And the original claim that was uploaded on the.
[AGENT][NEUTRAL] Third, OK, one that you initially gave me the claim number that ends in 93.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] We do need to still receive the diagnosis codes.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Wouldn't the diagnosis code be on the document that I send you?
[AGENT][NEUTRAL] It would be on
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] The itemized bill from the provider.
[CUSTOMER][NEUTRAL] I sent you
[CUSTOMER][NEUTRAL] Yeah, I, I.
[CUSTOMER][NEUTRAL] I sent that. Hold on, let me see where.
[CUSTOMER][NEGATIVE] And I, I know I had a really hard time sending it because it's like.
[CUSTOMER][NEUTRAL] It was submitted here it is. We had a my.
[CUSTOMER][NEUTRAL] was submitted on [PII].
[CUSTOMER][NEUTRAL] I submitted 5 files.
[CUSTOMER][NEUTRAL] And the last two files I submitted.
[CUSTOMER][NEUTRAL] Or uh which I.
[CUSTOMER][NEUTRAL] Titles A and B.
[CUSTOMER][NEUTRAL] It's the item I fill from the from the from Baptist Hospital.
[AGENT][NEUTRAL] OK, so yeah, I can get you connected, um, [PII] was one of the examiners who reviews this type of claim because I'm looking at that claim that was processed on.
[AGENT][NEUTRAL] That you send in the information the end of January and according to that when we were in need of the explanation of benefits from your primary insurance and then the we did need the diagnosis code.
[AGENT][NEUTRAL] According to that explanation of benefits as well.
[AGENT][NEUTRAL] And then it's
[CUSTOMER][NEUTRAL] And that's what
[CUSTOMER][NEUTRAL] And then I provided those.
[CUSTOMER][NEUTRAL] On
[CUSTOMER][NEUTRAL] On [PII].
[AGENT][NEUTRAL] I'm not seeing the diagnosis code. I see these are explanation of benefits.
[AGENT][NEUTRAL] From Aetna
[CUSTOMER][NEUTRAL] And the diagnosis
[CUSTOMER][NEUTRAL] The the I'm sorry, I understood that the diagnosis codes are on the itemized bill.
[AGENT][NEUTRAL] OK, this information, well, I'm sorry, we have a little bit of a lag in our call and it's, it's not that I'm trying to talk over you. There's just a slight delay.
[CUSTOMER][NEUTRAL] From back to
[CUSTOMER][NEUTRAL] From Baptist
[CUSTOMER][NEUTRAL] That's OK. I, I, I understand.
[AGENT][NEUTRAL] OK, so all I'm seeing on the 23 upload or explanation of benefits.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] Right, but what about on the 128?
[AGENT][NEUTRAL] Let me, um, the 128. Give me just a second.
[CUSTOMER][NEUTRAL] Where I uploaded the itemized bill from the hospital, wouldn't that have diagnosis codes on it?
[CUSTOMER][NEUTRAL] I mean, I don't know where else to get the diagnosis codes if it's not on the itemized bill.
[CUSTOMER][NEUTRAL] And how would Aetna have been able to, to
[CUSTOMER][NEUTRAL] To process the claims if they didn't have diagnosis codes.
[AGENT][NEUTRAL] The hospital would have had to provide them just like we have to have them provided to us.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] But, you know, again, that's based on the notes that I'm reading, that was something that we were missing. So give me, I'm trying to get the information that was
[AGENT][NEUTRAL] These are there.
[AGENT][NEUTRAL] I don't see a diagnosis code. I just see procedures that were done.
[AGENT][NEUTRAL] And bill date.
[CUSTOMER][NEUTRAL] OK, so how do I get the diagnosis code?
[AGENT][NEUTRAL] I'm still looking.
[AGENT][NEUTRAL] The hospital, to facilitate the provider that ordered.
[AGENT][NEUTRAL] OK, so since this was an inpatient admission, the hospital should be able to provide that.
[AGENT][NEUTRAL] To you
[CUSTOMER][NEUTRAL] And, and it wouldn't be on.
[AGENT][NEUTRAL] I can
[CUSTOMER][NEUTRAL] On their itemized bill.
[AGENT][NEUTRAL] I do not see that. I'm, I've been looking at the documents that you submitted initially. I do not see a diagnosis code. I see procedure codes, but I don't see a diagnosis code on here.
[AGENT][POSITIVE] Now again I um [PII], I'll be very happy to connect you.
[AGENT][NEUTRAL] With someone who can look at these documents to confirm that.
[CUSTOMER][NEUTRAL] OK, please.
[AGENT][NEUTRAL] But I am not seeing it and based on the review they were not seeing it so again, um, when I do connect you though you will not have to re-verify any of your information. I'm going to give them your policy number and let them know that we have already done that.
[AGENT][NEUTRAL] And let them know the information that you're needing to go over.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You are certainly very welcome. Is there anything else that I could help you with though before I connect you?
[CUSTOMER][NEUTRAL] Oh, I, I don't think so.
[AGENT][POSITIVE] OK, well thank you so much for calling APL and I hope that you have a very nice rest of your day today.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][POSITIVE] Yes ma'am, thank you so one moment please.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How can I help you?
[AGENT][NEUTRAL] Well, hey, [PII], it's [PII]. How are you?
[CUSTOMER][POSITIVE] I'm doing well [PII] thank you how are you?
[AGENT][NEUTRAL] I'm OK, thank you. Other than I have an insured on the line that's needing to go over several claims and the information that she has submitted. I've looked at the documents with, that we received. I've gone over the comments, but she feels like we have missed.
[AGENT][NEUTRAL] Something that it's already there. I mean that we have it.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, her policy number, [PII], is 1422256, and this is gonna be part two, [PII].
[AGENT][NEUTRAL] And her call back number?
[AGENT][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And she's referring, she's calling in regards to the last three again that we processed the [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And [PII].
[CUSTOMER][NEUTRAL] [PII] it's got [PII] to [PII].
[AGENT][NEUTRAL] And [PII].
[CUSTOMER][NEUTRAL] And [PII].
[AGENT][NEUTRAL] Uh-huh. Yeah.
[AGENT][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Yeah, pulling up some documents and everybody's been there uh everything's been verified [PII].
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Yes, ma'am. She is fully she's fully verified. Mhm, including part one's information.
[CUSTOMER][NEUTRAL] And part two is uh who's on the line, right?
[AGENT][NEUTRAL] On the line, that is correct, yes. And all these claims are for her. And she thought that she, you know, that we, she had gotten everything. I didn't see a diagnosis code being received. I tried to, she was concerned about the um Miami-Dade Fire and Rescue. I looked at that EOB of what she sent doesn't reflect that there was anything.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Applied to the three areas. So I tried to explain that to her, but anyway.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Hm.
[AGENT][NEUTRAL] I think everything is correct. I didn't, you know, and I explained that she would need to, you know, contact the facility to get the diagnosis code.
[CUSTOMER][NEUTRAL] OK, yeah, a lot of times they get the diagnosis and disease are mixed up and they think that we're asking for information, right.
[AGENT][NEUTRAL] But
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And I, right, and I told her that um what I um what we received rather what I could see was a lot was procedures, things that she had had done but not a diagnosis code. But anyway.
[AGENT][NEUTRAL] Because those so many of those documents started overlap. I mean, you know, that's.
[AGENT][NEUTRAL] Lots of dates of service.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] On those 3 claims.
[CUSTOMER][NEUTRAL] Yeah, I'm looking at it now and that's all I see is procedures and.
[AGENT][NEUTRAL] And they overlap.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] That's why it's better if they have the facility just submit on their behalf because they don't show that home or deductible.
[AGENT][POSITIVE] Right. And I encour mhm and I encourage them.
[AGENT][NEUTRAL] On every call I take.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] To have the provider do it if they will.
[CUSTOMER][NEUTRAL] I know.
[CUSTOMER][NEGATIVE] Yeah, yeah, and that's one page I can't even read anything oh.
[AGENT][NEUTRAL] But anyway,
[CUSTOMER][NEUTRAL] OK, maybe that's just a duplicate of that page. I don't know I hard to do.
[CUSTOMER][POSITIVE] OK, well, I'm looking at them now so you can go ahead and patch her through. I'll do my best.
[AGENT][NEUTRAL] OK, [PII].
[AGENT][POSITIVE] You, you always do excellent and I appreciate it. So, thank you.
[CUSTOMER][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Alright have a good afternoon if I don't talk to you again, OK.
[CUSTOMER][POSITIVE] You too you too thank you.
[AGENT][POSITIVE] You're welcome. Bye-bye.
[CUSTOMER][NEUTRAL] Alright bye.