AccountId: 011433970860
ContactId: 88518379-4089-4fb2-a0df-28f28674f202
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 985679 ms
Total Talk Time (AGENT): 251139 ms
Total Talk Time (CUSTOMER): 405611 ms
Interruptions: 1
Overall Sentiment: AGENT=0.5, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/24/88518379-4089-4fb2-a0df-28f28674f202_20250124T20:36_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Oh hi, my name is [PII].
[CUSTOMER][NEUTRAL] And I'm just wondering the status of um some of our claims. I submitted something.
[CUSTOMER][NEUTRAL] For my husband.
[CUSTOMER][NEUTRAL] And um I don't know, for some reason, only I, I submitted two EOBs from our primary United Health.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] And one of them was paid and the other one wasn't, I don't know if it was because you couldn't read it or because it was denied. That's not clear to me.
[AGENT][POSITIVE] Yes, I can check on that for you, Ms. [PII]. Um, may I have a callback number just in case we get disconnected? You're welcome.
[CUSTOMER][POSITIVE] Thank you so much.
[CUSTOMER][NEUTRAL] Yes, it's [PII].
[AGENT][NEUTRAL] OK, thank you. And may I have the policy number?
[CUSTOMER][NEUTRAL] Uh, the APL policy number. Oh, I, that's in my purse. I'm sorry. I should have had that. Wait a minute.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] I think it's on the paperwork, but here I can go get my purse quickly.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] It is.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] 01660258 M like monkey L [PII].
[AGENT][NEUTRAL] Thank you. May I have your date of birth for security?
[CUSTOMER][NEUTRAL] Um, so it's my husband, so it's [PII]. Do you need mine too?
[AGENT][NEUTRAL] Yes, please.
[CUSTOMER][NEUTRAL] And mine is [PII].
[AGENT][NEUTRAL] Mm thank you Mr. [PII] and I need to verify the mailing address on file.
[CUSTOMER][NEUTRAL] Um, so we have two mailing addresses, but I believe the one on file with you is [PII].
[AGENT][NEUTRAL] OK, yes, thank you, and that's what we have. Thank you. One moment, let me check the claims.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] OK. So what date of service do you have in question? Is it the same date of service of [PII] and [PII]?
[CUSTOMER][NEUTRAL] OK. Let me look.
[CUSTOMER][NEUTRAL] Yes, one is [PII].
[CUSTOMER][NEUTRAL] And the other,
[CUSTOMER][NEUTRAL] Well,
[CUSTOMER][NEUTRAL] The ones that I have in front of me are all [PII] sounds familiar to in a minute with this.
[CUSTOMER][NEUTRAL] Um, let me see.
[CUSTOMER][NEUTRAL] They're 2 on [PII] and we got paid for one of them.
[CUSTOMER][NEUTRAL] The other one I don't know if it was paid or denied or.
[CUSTOMER][NEUTRAL] Wait a minute now let me, let me just look at this other one and see if it's the [PII].
[CUSTOMER][NEUTRAL] Do you have 2 of them on the [PII] or only 1?
[AGENT][NEGATIVE] OK, on the [PII], I got 1234 that we paid 3 and one of them was denied because office visits are not covered.
[CUSTOMER][NEUTRAL] OK, wait a minute. Maybe these other ones are also the [PII], sorry.
[CUSTOMER][NEUTRAL] Yeah, well I don't have.
[CUSTOMER][NEUTRAL] No, these other ones are the [PII].
[CUSTOMER][NEUTRAL] Um, OK, so can you tell me the amounts? Um, one was for 2:10 on the [PII], correct?
[AGENT][NEUTRAL] OK, the 210 is uh a combination of several claims, several products that we've paid, um, like, um, let's see.
[CUSTOMER][NEUTRAL] But it's not
[CUSTOMER][NEUTRAL] So, so wait a minute. I have, I have the EOBs from United and one EOB is for 210, and another 10, these are both 210. Wait a minute.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And another one is 453 39.
[AGENT][NEUTRAL] OK, so we send the payment for 10.
[CUSTOMER][NEUTRAL] You don't have those?
[CUSTOMER][NEUTRAL] Yes, you have the I, we didn't get the payment, but I see that it was paid.
[AGENT][NEUTRAL] Mhm. It was um processed on the [PII]. Mhm, correct.
[CUSTOMER][NEUTRAL] Or approved at least.
[CUSTOMER][NEUTRAL] And was that, can you check with that mailed to us cause my husband already paid the doctor.
[AGENT][NEUTRAL] Yes, it was mailed to the insured.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and the only other thing that I see that we did not pay was the office visit, which is not payable under this policy.
[CUSTOMER][NEUTRAL] So that one
[CUSTOMER][NEUTRAL] And that
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Let me just see. I don't know why I have multiples of the, they might just be the same thing. Let me, yeah, this is a repeat of everything, um.
[CUSTOMER][NEUTRAL] And the one that totals 453 39, do you have that one?
[AGENT][NEUTRAL] I don't see one for that amount unless they are adding the 280 which is uh the office visit. Let me add this together and see if that's what comes.
[CUSTOMER][NEUTRAL] OK, so they would add 280 to what? To make 453 39.
[AGENT][NEUTRAL] To the, to, um, let me go ahead and find out if that's, if that's the case because I don't see another one for that amount. I don't see anything for 45339.
[CUSTOMER][NEUTRAL] Yeah, that's
[CUSTOMER][NEUTRAL] That's what I'm thinking. I'm thinking maybe it couldn't be red or something.
[CUSTOMER][NEUTRAL] Cause I see that I, it was on my, I'm pretty sure I saw it submitted when it says it online.
[CUSTOMER][NEUTRAL] At the same time I submitted the 210.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] If not, I can redo it.
[CUSTOMER][NEUTRAL] And then this other one and this one.
[AGENT][NEUTRAL] No, ma'am.
[AGENT][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Let me go ahead and pull the documents, OK? Do you mind holding for me?
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] No, not at all. Thank you.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Thank you for holding and being patient for me, Mr. [PII].
[CUSTOMER][POSITIVE] No problem. Yeah.
[AGENT][NEUTRAL] OK, so I'm looking at the explanation of benefits um from the primary insurance that you um send us. The 45339, it composed of the $190 we send the $5 we send, the $10 we send, the other $5 we send, and the $24339 for the office visit, which that one is not covered because it's an office visit.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, so, um, and who did you send?
[CUSTOMER][NEUTRAL] The 195, 10 and 5, does that equal to 10?
[AGENT][NEUTRAL] That's gonna be $210 and there's a separate payment for $5. So um let's see.
[CUSTOMER][NEUTRAL] So wait a minute, so why?
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] Yeah, it's $210 altogether. I do apologize. It's $210. It's 190 $10 it's 20 $5.05. Mhm.
[CUSTOMER][NEUTRAL] OK, so
[CUSTOMER][NEUTRAL] 19525.
[CUSTOMER][NEUTRAL] Got it. OK, now I understand it. OK. Now, what about the [PII], the visit on [PII]?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, let me check on that.
[CUSTOMER][NEUTRAL] What do you have done for that?
[CUSTOMER][NEUTRAL] No, I'm looking on United Healthcare right now to see.
[CUSTOMER][NEUTRAL] Let me see what kind of a
[AGENT][NEUTRAL] OK, so that one was denied. Let me check why.
[CUSTOMER][NEUTRAL] I'm trying to see if I can even find it on United Healthcare.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It it will be on the first documents that you uploaded. I saw it there. I just need to check and see what.
[AGENT][NEUTRAL] What is the denial reason.
[CUSTOMER][NEGATIVE] I, I cannot, I cannot find it on my healthcare.
[CUSTOMER][NEUTRAL] Is it just pharmacy?
[AGENT][NEGATIVE] Yeah, and that's why it's denied. Yeah, it's a pharmacy and that's why it was denied because we don't cover pharmacy.
[CUSTOMER][NEUTRAL] The only thing I can
[CUSTOMER][NEUTRAL] And how much was that for?
[CUSTOMER][NEUTRAL] Because I don't see it.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Looks like it was $180.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So you're not, so we don't get, I thought that anything that the main insurance covers, you cover the rest of for us.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] Can you tell me, did it say insulin syringe?
[CUSTOMER][NEUTRAL] Because here it only says $3.20.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] OK, are you looking at our explanation of benefits or their explanation of benefits?
[CUSTOMER][NEUTRAL] On United Health.
[CUSTOMER][NEUTRAL] I'm looking at United Healthcare for, for 9, like I don't see anything like.
[CUSTOMER][NEUTRAL] What is the paper that I submitted?
[CUSTOMER][NEUTRAL] Dated [PII]. What does that have on it?
[AGENT][NEUTRAL] OK, um, the paper that that we are seeing it has um.
[AGENT][NEUTRAL] Let's see, $180.
[AGENT][NEUTRAL] And this this is for um
[AGENT][NEUTRAL] Prescription drug medicine.
[CUSTOMER][NEUTRAL] Oh, it was a total of 180?
[AGENT][NEUTRAL] Um, I believe so let me double check, make sure.
[CUSTOMER][NEUTRAL] How come I don't see it?
[AGENT][NEUTRAL] Let me pull that image one more time, OK? Let me pull that image one more time.
[CUSTOMER][NEUTRAL] Yeah, and I don't even see it listed on on online under APL. I don't see a oh, I don't see a date of [PII]. There's one for me for [PII] but not for my husband.
[AGENT][NEGATIVE] It is on the explanation of benefits. It says RX and it's denied under the explanation of benefits, um.
[CUSTOMER][NEUTRAL] It said, and it was because under United Healthcare, they don't have anything for 180. They just have $3.20.
[CUSTOMER][NEUTRAL] So that's why, and I can't.
[AGENT][NEUTRAL] It's for Optum Optum RX.
[CUSTOMER][NEUTRAL] I can't, I.
[CUSTOMER][NEUTRAL] Do you know what date I I submitted it to you? Because I can't find it so if I can get it offline and I can print it out again.
[AGENT][NEUTRAL] It's the same day that you submitted the claim online. Um, I'm looking at the same claim which it was on [PII].
[CUSTOMER][NEUTRAL] OK, wait a minute.
[CUSTOMER][NEUTRAL] OK, so I might be able to look this up. Wait a minute now. So I submitted, oh Optum RX is that it?
[AGENT][NEUTRAL] Yes, uh-huh.
[CUSTOMER][NEUTRAL] And it says
[CUSTOMER][NEUTRAL] 19,180, there it is. OK. Pharmacy receipt. OK. So I submitted that. I got that and then
[CUSTOMER][NEUTRAL] Wait a minute, few files and then the other thing I submitted that day.
[CUSTOMER][NEUTRAL] Was the 4:53 and the 210, correct?
[AGENT][NEUTRAL] The 210 is part of the 453, yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right, got it. OK, I understand it all. So I'll go back to my husband and I'll, I don't know why he, he's, he left me a note that he called you on [PII] and explained it all and for some reason you all were gonna pay the pharmaceutical one to the pharmacy one too.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Do you have any notes from [PII] of, oh no, that was me [PII] no wait that's me. That's when I texted it to you. That's when I.
[AGENT][NEUTRAL] Um, we don't
[CUSTOMER][NEUTRAL] Uh, fax it to you, handed it to you. Um, let me see when he.
[AGENT][NEUTRAL] Mm, yeah.
[AGENT][NEUTRAL] We do not cover pharmaceuticals on this one.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It's under the contract of the policy.
[CUSTOMER][NEUTRAL] So I don't know. So I'm gonna have to go back to him and see what he says, maybe call you back. I don't know what he's talking about. But anyway, thank you.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Mm.
[AGENT][POSITIVE] You're welc[PII]. Is there anything else I may help you with today?
[CUSTOMER][POSITIVE] Um, no, that's it right now. Thank you so much.
[AGENT][POSITIVE] No, no, you're welcome, Mr. [PII] and thank you for calling APL. Have a good afternoon.
[CUSTOMER][NEUTRAL] You too. Bye-bye.
[AGENT][POSITIVE] Thank you. Bye-bye.