AccountId: 011433970860
ContactId: 8c485278-1b77-4357-b87c-8b6d7a1fe991
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 505119 ms
Total Talk Time (AGENT): 177070 ms
Total Talk Time (CUSTOMER): 255085 ms
Interruptions: 0
Overall Sentiment: AGENT=0.4, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/09/8c485278-1b77-4357-b87c-8b6d7a1fe991_20250609T22:04_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. May I help you?
[CUSTOMER][NEUTRAL] Hi, I have a question. I'm trying to get a stat update on a claim that was sent from a surgical, um, from a hospital.
[AGENT][NEUTRAL] OK, I can verify claim status for you and your name is?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And Ms. [PII], do you have the policy number?
[CUSTOMER][NEUTRAL] Do it is under my husband's name. His name is [PII].
[CUSTOMER][NEUTRAL] And the policy number is 02297912.
[AGENT][POSITIVE] OK, thank you one moment.
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] OK, and Ms. [PII], verify your date of birth and the mailing address, please.
[CUSTOMER][NEUTRAL] [PII] and [PII].
[AGENT][NEUTRAL] OK, thank you. And this is a claim for Mr. [PII] or for yourself?
[CUSTOMER][NEUTRAL] No, this is a claim for myself for [PII].
[AGENT][NEUTRAL] Uh, what was that date of service?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And I called a couple of weeks ago about this as well, so.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And this was for what's the name of the provider?
[CUSTOMER][NEUTRAL] Um, the provider's name or is it a hospital name?
[AGENT][NEUTRAL] Uh, either one.
[CUSTOMER][NEUTRAL] It was first. So it's the hospital with Saint Luke's Presbyterian. It also has the HCA Health one, like must be the parent company, and the doctor was Doctor [PII].
[CUSTOMER][POSITIVE] As well as nurse practitioner [PII].
[AGENT][NEUTRAL] OK, give me one moment.
[AGENT][NEUTRAL] Uh, I show that claim process is needing itemized bill with the diagnosis codes and the primary insurance EOB or explanation of benefits for that data service.
[CUSTOMER][NEUTRAL] I'm sorry, can you repeat that? I didn't understand the first part of what you said.
[AGENT][NEUTRAL] Uh, said I show the claim received and processed as needing the itemized bill showing the diagnosis and procedure codes.
[CUSTOMER][NEUTRAL] And so did you guys send and ask for that or there's already?
[AGENT][NEUTRAL] No, ma'am, uh, this looks like it was an insured submission, so it was, um, explanation of benefits was mailed out on the 2nd to y'all as needing the itemized bill and primary EOB.
[AGENT][NEUTRAL] This claim was not submitted by the provider.
[CUSTOMER][NEUTRAL] So the claim was submitted by the hospital, correct?
[AGENT][NEUTRAL] No, ma'am, it was not submitted by the hospital. It looks like an insured submitted claim.
[CUSTOMER][NEUTRAL] Who was it submitted by?
[CUSTOMER][NEUTRAL] So I was told by Health One who's the parent company of the hospital that they sent.
[CUSTOMER][NEUTRAL] Over
[CUSTOMER][NEUTRAL] Uh, the information to you.
[CUSTOMER][NEUTRAL] So you're stating that Aetna sent the information to you?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] No, not Aetna, but it looks like an insured, like you or your husband submitted the claim. It wasn't submitted by a provider, like a facility or a physician.
[CUSTOMER][NEGATIVE] No, neither one of us submitted a claim for that. Uh, last time that we spoke, if you can see notes, if your system does that, I spoke to one of your representatives and I had to have the hospital resubmit it over to you because the reason why the hospital is not crediting crediting us $5000 back that we are deserved is because they're waiting on.
[CUSTOMER][NEUTRAL] What you guys are going to cover that's what was spoken about. And when I spoke to the representative at your establishment, they said that OK we received the claim and it'll take 14 to 75 days to go through so I'm a little confused on what you're seeing because I did not submit anything to you directly. It would have either been the hospital or the practitioner.
[AGENT][NEUTRAL] Uh, we haven't received any claims from any provider, the hospital nor the physician.
[CUSTOMER][NEUTRAL] So the hospital stated that they sent the claim twice to the number that I called and your representative gave it to them.
[CUSTOMER][NEGATIVE] So like I'm a little confused on how this is like so not like I I I I just don't understand what's happening if the hospital's billing stated twice that they've sent APL with the number I was given this claim why it's showing that myself or my husband submitted a claim that we've never submitted.
[AGENT][NEUTRAL] Well, we received a claim for that data service for anesthesiology, which was processed, but we hadn't received any other claims from like the facility nor the physician. So, only thing I can suggest is you can call them and let them know we have not submitted uh received the claim, and they wouldn't have to wait for us um and for, in order to process cause this is secondary policy only. So we would need the primary EOB.
[CUSTOMER][NEGATIVE] OK, I'm so confused this process is like outrageously ridiculous to me. Can you please tell me what number once again that they would submit said claim to you?
[AGENT][NEUTRAL] Our fax number [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So on the claim that you said looks like was submitted by me or my husband, is there a way that you can email us a copy of what that looks like because neither one of us submitted anything to you.
[AGENT][NEUTRAL] Because what it looks like it's not a bill. It looks like a receipt, um, to whom it may concern according to our records, the above reference claim for your insurer was submitted over 90 days ago and it's not paid on behalf of. Please consider demand. I guess this is what you're saying they said they sent, but it's just a notification that they haven't received anything from us, but we have not received any claims for them.
[CUSTOMER][NEUTRAL] Yeah, we didn't
[CUSTOMER][NEUTRAL] This is so crazy. OK, can you please, uh, so I'm about to have another big major surgery and I may not have the cognition to handle this for about a month. Is there a way that you can make a note in my chart that when you receive that claim from the hospital, you either send some type of email to my husband or call one of us to state that you have received it.
[CUSTOMER][NEUTRAL] Because I just don't think it's like a reasonable thing to ask people to call every single week to see if somebody received a claim. So is there any way you can notify us if you get something from the hospital?
[AGENT][NEUTRAL] Well, it's not something that we do except for when the claim has been received and then processed, and an explanation of benefits is sent. Uh, we do have an online service center where your husband can set up an account since he is the policyholder to where he can receive any texts, um, when a claim has been received and also when a claim has been processed.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, that's good. I will let, I will call, I will have him do that, so I'll have him set that up right now and then I'm gonna call back this hospital because I really think it's them that has the problem. So um thank you for your help. I will call them back now.
[AGENT][POSITIVE] Alright, you're welcome, Ms. [PII], and thank you for calling APL. Have a great day.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Bye.