AccountId: 011433970860
ContactId: 87b20710-7d3d-4b15-bce3-30d878730b2e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 813840 ms
Total Talk Time (AGENT): 300025 ms
Total Talk Time (CUSTOMER): 226305 ms
Interruptions: 0
Overall Sentiment: AGENT=0.3, CUSTOMER=-1.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/29/87b20710-7d3d-4b15-bce3-30d878730b2e_20250129T13:49_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Good morning, [PII]. My name is [PII]. I'm calling about a claim I filed for my spouse, [PII]. This has been ongoing for a long time.
[CUSTOMER][NEUTRAL] I recently provided the um.
[CUSTOMER][NEUTRAL] The code that was requested and I'm checking to see if it was accepted for payment of the $300.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, well, I can definitely check the claim for you um and provide you with an update. And Mrs. [PII], may I have a good contact number in case we're disconnected and then the policy number?
[CUSTOMER][NEUTRAL] This is Mr. [PII] and the best contact number is [PII].
[AGENT][NEUTRAL] Thank you for that. And Mr. [PII], may I have your policy number?
[CUSTOMER][NEUTRAL] Policy number is 17672.
[CUSTOMER][NEUTRAL] That's a group number. I don't have a policy number per se.
[AGENT][NEUTRAL] Group, OK, hold on one moment.
[AGENT][NEUTRAL] 17672.
[AGENT][NEUTRAL] OK, and I believe I just um found your policy. I just need you to verify your date of birth, the mailing address and email address on file.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Address is [PII].
[CUSTOMER][NEUTRAL] [PII] and my
[AGENT][NEUTRAL] Email.
[CUSTOMER][NEUTRAL] Yeah, my email is uh uh my first name, [PII].
[AGENT][NEUTRAL] Alrighty, thank you so much for verifying your information. And Mr. [PII], is it alright if I place you on just a brief hold while I take a look at the claims?
[CUSTOMER][NEUTRAL] Sure, go right ahead.
[AGENT][NEUTRAL] All right, hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] What now?
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] What?
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] I don't see anything that says diagnosis or miscellaneous. So is this the same thing?
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, wait a minute.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] It's question.
[AGENT][NEUTRAL] Alright miscellaneous is.
[AGENT][NEUTRAL] OK, wait a minute. So [PII] is not covered because it's an office visit, OK?
[AGENT][NEUTRAL] R E M R
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] B H.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Hello, Mr. [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Thank you so much for holding. I apologize for that wait. Um, I had to do a little back and forth with the claims, but I do see um where everything was received and the claim was denied as of yesterday. There's a few reasons though. The Cleveland Clinic portion of it, office visits are not covered on the policy.
[AGENT][NEUTRAL] And then um for the
[AGENT][NEUTRAL] MRI for the Palm MRI Imaging Center.
[AGENT][NEGATIVE] One of them was denied because Primary paid the full balance, so we couldn't pay it. This one was $1300 but from the explanation of benefits, Primary insurance paid all of that, so there was nothing left to pay. And then
[CUSTOMER][NEUTRAL] Yeah, but there was a there was a deductible of $300 which was paid by my wife. I thought this insurance allows the repayment of any deductible that you pay out of pocket. Why is that being denied?
[AGENT][NEUTRAL] It's of covered charges. So we do apply to the co-pay, deductible and co-insurance after primary of covered charges. So if there is a deductible that was um charged, but on your secondary insurance, the cover there's no coverage for it, we can't, we still can't pay out.
[AGENT][POSITIVE] Your primary has its own benefits and secondary has its own benefits.
[CUSTOMER][NEGATIVE] So I guess there's no use in me having APL then if I have to pay for uh a special procedure. I'm not gonna be reimbursed.
[CUSTOMER][NEUTRAL] Since when is this happening?
[AGENT][NEUTRAL] Well, I don't, I don't
[AGENT][NEUTRAL] I don't want to say that. It's just if you like I can send you a copy of your coverage so you know what is covered, so that, you know, if it's something that's not on there, you'll know, you can't use your secondary.
[CUSTOMER][NEUTRAL] If
[CUSTOMER][NEUTRAL] There, there's, there's been, there's been previous incidents where I paid out of pocket for MRI's and it was reimbursed.
[AGENT][NEUTRAL] Right, so we're talking about two different things. So your MRI would have been covered, but the primary insurance paid it. So we can't, if there's, if there's no balance, we can't pay on it.
[CUSTOMER][NEUTRAL] However, this
[AGENT][NEUTRAL] If primary had not
[CUSTOMER][NEUTRAL] Well, you're not paying the primary insurers, you're not paying the reimbursing the primary, you're reimbursing the, the participant in your plan for the money that came out of pocket.
[AGENT][NEUTRAL] Right, but if for your, if your, if the service is not covered for your secondary insurance, even if you had to pay for primary, if your secondary benefits don't cover it, we cannot pay out. We would have been able to for the
[CUSTOMER][NEUTRAL] So you don't cover.
[CUSTOMER][NEUTRAL] You do not cover MRIs?
[AGENT][NEUTRAL] That's not, that's what I'm saying. You're speaking of two different things. So on this claim, there's 3 different things that were claimed for the
[CUSTOMER][NEUTRAL] No, there, there was one thing, uh, there's one thing, I guess they've all been commingled now because I've been trying to get it done so lo[PII]. The only thing I'm asking for in my claim was for reimbursement of $300 out of pocket. I, I'm here in Cleveland Clinic involved in this.
[CUSTOMER][NEGATIVE] In this response, but this does not involve anything this has nothing to do with Cleveland Clinic. This was just with Palm MRI. When we went to Palm MRI for her to get the procedure done, which was an MRI, she had to pay them $300. That is all I'm requesting to be reimbursed. What they requested of me is the, the diagnostic code, which I could not.
[CUSTOMER][NEUTRAL] Fine on my explanation of benefits which was provided by Amet, I subsequently contacted MRI, who is now out of business, so it was plenty to get them to give us the diagnostic code which I provided you in my last upload. So the diagnostic code was to go against my claim for $300 for uh payment um MRI.
[CUSTOMER][NEUTRAL] What am I missing in that, please?
[AGENT][NEUTRAL] Uh, so the only other way that I can explain it, I mean, if your primary insurance pays everything, there's nothing left to pay.
[CUSTOMER][NEGATIVE] They did not fit
[CUSTOMER][NEGATIVE] They did not pay the entire balance. so why was she charged 300?
[AGENT][NEUTRAL] So let's do this. Let's do this. Let's do this. Let me go ahead and get a claims examiner on the line so that they can go into this more in detail with you because they examined the claim and then they'll be able to answer these questions for you because I
[AGENT][NEUTRAL] If it's not covered, we can't, we can't pay out. Um, I, I can definitely get an examiner on the line though to see if they can offer you some more in detail, um, explanation if you'd like.
[CUSTOMER][NEUTRAL] Please do, please do.
[AGENT][NEUTRAL] Sure, before I do that, was there anything else I could assist you with today?
[CUSTOMER][POSITIVE] No, that is it thank you.
[AGENT][NEUTRAL] You're welcome. Hold on one moment and thanks for calling APL.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] There ain't nothing else to say.
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][NEUTRAL] This is [PII]. May I help you?
[AGENT][NEUTRAL] Hey, [PII], my name is, my name is, I'm [PII] calling from the care team. How are you?
[CUSTOMER][POSITIVE] Good, how are you?
[AGENT][NEUTRAL] I'm doing good. I have an insured on the other line. Um, can I give you the policy number?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, it's 142.
[AGENT][NEUTRAL] 356 3.
[AGENT][NEUTRAL] Uh, it's for part two.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And it's
[AGENT][NEUTRAL] Um, the claim number 3508589 was the denial that asked for the diagnosis code and then that last claim there processed was the redo.
[CUSTOMER][NEUTRAL] What, you said 350?
[AGENT][NEUTRAL] Mhm. 858-9.
[CUSTOMER][NEUTRAL] Data service 18.
[AGENT][NEUTRAL] Uh, and 111.
[CUSTOMER][NEUTRAL] 111.
[AGENT][NEUTRAL] So they sent in the diagnosis codes, we reprocessed and then
[AGENT][NEUTRAL] His thing is, why wasn't he reimbursed for the
[AGENT][NEUTRAL] Um, deductible. I went over everything with him. I explained the provider, I mean not the provider, primary insurance paid. I went through all the reasons, explained it about three different ways. He still does not understand why we did not pay or reimburse him for the deductible.
[AGENT][NEUTRAL] And he wants to speak with someone else.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, uh, hold on one moment, OK?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Hello, Mr. [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Thank you so much for holding. I have [PII] on the line and she'll be assisting you further, OK?
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] This is [PII]. May I help