AccountId: 011433970860
ContactId: 8c6778bb-a957-4ef5-aa0a-d9df88cf15af
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 647739 ms
Total Talk Time (AGENT): 154364 ms
Total Talk Time (CUSTOMER): 497536 ms
Interruptions: 7
Overall Sentiment: AGENT=0.6, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/30/8c6778bb-a957-4ef5-aa0a-d9df88cf15af_20250530T18:07_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], it's [PII] in the care team. I've got an insured on the phone. Her name is [PII].
[AGENT][NEUTRAL] Hi.
[CUSTOMER][NEUTRAL] Um, her policy number is 251-9419, and she's been verified.
[CUSTOMER][POSITIVE] Um, the number she's calling from is a good call back number.
[CUSTOMER][NEUTRAL] And she's calling about claim number 3604043. I read her the remarks on the claim, and she has uh further questions about the claim so and she wanted to speak to somebody so I'm transferring her on over to you guys now.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so you didn't know what she was, what her question was.
[CUSTOMER][NEGATIVE] I am very confused about what she's wanting. She's talking about um.
[CUSTOMER][NEUTRAL] The part of the claim that the insurance provided full benefits, but she said there's a second part to the claim that's gonna be $217 and she wants me to make notes that there's gonna be a second part, and I told her I can't do notes like that that I'm not in the claims department that if there's a second part to the claim, it sounds like it needs to be submitted, but she's she's going all over the place with this claim.
[AGENT][NEUTRAL] OK, so it sounds like there's gonna be a new, another claim that we're, we most likely was received down the road that we just haven't received yet.
[CUSTOMER][NEUTRAL] That's what I'm thinking too, but she wants specific notes put in the system and I told her I cannot put those notes because I don't have that information in my hand to write those notes so.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, you can send it to me.
[CUSTOMER][POSITIVE] OK. All right. Thank you so much, [PII]. Hm bye-bye.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Claims department, this is [PII].
[CUSTOMER][NEUTRAL] Hello. Uh, hi, my name is [PII]. I'm sorry, what's your name?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII]. Hello, [PII]. Good morning. How are you doing?
[AGENT][NEUTRAL] Hi, I'm fine. How about you?
[CUSTOMER][NEUTRAL] I'm good thank you. Uh, well, actually maybe I'll be better if you guys help take care of this. It's been an ongoing thing. Um, I just spoke to [PII] and she transferred me to your department, so I got this, uh, explanation of benefits. Do you need to pull up my claim number, uh, [PII]?
[AGENT][NEUTRAL] No, she gave me, [PII] gave me that information. I have the claim information pulled up. So [PII], you had a question in regards to the data service of [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Then we processed
[CUSTOMER][NEUTRAL] Well, yeah, what it is is that I don't know how the doctor's office bills you guys, but basically at the end of the year, um, you know, I pay my uh my, my co-pay and then I have this uh procedure that I need to get done uh to reduce the pressure for my glaucoma, the pressure.
[CUSTOMER][NEUTRAL] In my eyes, so the the procedure consists of three laser zaps, and so, um, it's a total of $210. So they said that, you know, each time I go it'll be spread apart uh $70 each will be 2 $10 total and I said that um after paying my.
[CUSTOMER][NEGATIVE] A specialty visit. I go to the procedure for the 210. I should be billed to my APL if my insurance doesn't cover it because that's what my, you know, APL is for. It's supplemental that I had for like 2 or 3 years that I haven't had to use it, so I'm thinking you guys wouldn't have any problem paying this $210. So I got this explanation of benefit, and I don't know how the doctor bills it, but I see that it seems like you guys paid them the $70 only, right?
[AGENT][NEUTRAL] Yes, so it looks like on this claim, it looks like the total bill amount was $1140. It looks like based off your primary.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Insurance care Cigna, your co-pay was applied towards.
[CUSTOMER][NEGATIVE] I don't know why they even billed you guys for 11.
[AGENT][NEUTRAL] The co-pay was $70.
[CUSTOMER][NEUTRAL] Yeah, I don't even know what they built.
[CUSTOMER][NEUTRAL] Mhm. So I was responsible for this.
[AGENT][NEUTRAL] So that was the amount that we picked up.
[CUSTOMER][NEUTRAL] Yeah, the thing is that I don't even know why they bill you for 11:40 because it should be billed to my primary which pays for everything. The only thing that they didn't pay for is the, the procedure itself that's 210. So, uh, I'm gonna let them know because you know I came, I went to for a follow up visit a few, um, so my the first.
[CUSTOMER][POSITIVE] It's uh it's a 3 series procedure, so it started at the end of the year and I was all done by I think February or something like that and uh so a few weeks ago with my follow up you have after a few months you go follow up to see how, you know, the laser helped reduce the pressure in my eye and that's when they say that I owe the 210 that the 210 was never paid for by APL. So then I said that, uh, well, can you show me.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] That they deny or anything they didn't have anything for me so they said they'll try to bill it again. So this was just maybe 2, 2-3 weeks ago. So when I got this letter already, so I don't know it's in transition, but anyhow, I don't know how they bill you guys but um would you be able to put a note, [PII] that um.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] That the remaining of the 2/10 of the 140 that that they're supposed to well they tell me that I owe them 210 but it shows here that you guys paid them $70 so really we only owe them another $140 for that procedure. Can you put a note somewhere that they will be billing?
[AGENT][NEUTRAL] So [PII], it sounds like maybe we haven't, they have not filed that claim with us yet. So on this claim, the total charge amount was for 1140. It was submitted to your primary insurance carrier, which was Cigna. They did pay a portion of this claim, and then we picked up as your secondary.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Where your out of pocket was towards your copay was $70 so it sounds like the, the additional money that you're referring to may be a claim that they have not filed with us yet. We don't have that claim on file. We only have this claim where you're out of pocket with $70 so far.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, I don't.
[CUSTOMER][NEUTRAL] Yeah, I guess what I'm trying to say is that the whole procedure is 210, but because they told me that I didn't have to pay it all at once, that, you know, each for each, uh, laser session they just charged 70 at a time and by the third time it'll be the 210 and I asked them to, you know, bill APL and I guess they, I don't know how they build it, but would you, so I'm gonna explain to them that because then you know this procedure was done.
[CUSTOMER][NEUTRAL] The end of the year to the beginning of the year, so it's been a while and we're in June now so they're telling me that you know they couldn't collect and they want me to pay so I'm gonna have them bill you guys or send a claim that you're saying that they didn't do other than the one the end of the year so.
[AGENT][NEUTRAL] Yeah, I don't show that this claim we have is for 210. This claim we have is not for 210, so we don't have that claim on file yet.
[CUSTOMER][NEUTRAL] Yeah, so.
[CUSTOMER][NEUTRAL] Yeah, so, yeah, so can you do me, I don't, I guess the jumbling up.
[CUSTOMER][NEUTRAL] You know what they're billing in total versus what what because they told me that the my primary doesn't pay for.
[CUSTOMER][NEUTRAL] You know, the, the, uh, the procedure that that that's extra, I guess, right? Like the, the normal visit and all that is all covered for I just pay my de.
[CUSTOMER][NEUTRAL] My, my specialty visit each time, but the 210 was supposed to be covered by APL and so I don't know how they bill you guys, um, but if you can help put a note in the system, you know, that the remaining that they will be billing for the $140 is part of the same procedure so that it doesn't sound confusing that they're trying to build another whole set of procedures, you know what I mean.
[AGENT][NEUTRAL] So, is this for the same date of service of [PII] where the procedure of 210 occurred?
[CUSTOMER][NEUTRAL] It was just one.
[CUSTOMER][NEUTRAL] Yeah, it's not, it's the procedure is a 3 series uh laser zap in my eyes to lower the pressure, see how you, so it's spaced out, but it's a one, it's a, it's a, it's considered a one procedure. So I guess I just like you to put a note in the system that it's one procedure so that it doesn't sound like I'm getting multiple procedures and then they're trying to bill you.
[CUSTOMER][NEGATIVE] Each time for a grand or for a large amount, you know what I mean? It should be you guys should only need to pay them another $140.
[CUSTOMER][NEUTRAL] Does that make sense? Maybe you can put a note in the system that.
[AGENT][NEUTRAL] So we can only consider benefits based off the information that we re that is filed by the um provider. So depending on when that claim is filed, we can determine benefits based off that information. We can't determine benefits as of right now we don't have a claim on file. The only thing that we can do as far as make a note that there may be potential claims that may be submitted by the provider.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes, OK.
[CUSTOMER][NEUTRAL] Yeah, from, from that previous, uh, procedure, maybe just a note or something like that so they'll know that it's something that's been done already and not recent procedures. Does that make sense? Maybe just say that, uh, the provider will be billing the remaining from that procedure that was initiated the end of the year.
[AGENT][NEUTRAL] So when they file a claim, it'll have the data service in those procedure codes. So once we have that from the provider, we can consider that claim because that it'll it'll show the data service, it will show the procedure codes and all that information when they submit the claim to us.
[CUSTOMER][POSITIVE] I'm thinking that might help.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, well, I don't know how they'll send it, but I'll let them know that they need to send it to uh send a claim to you guys that you guys haven't received it other than that one.
[CUSTOMER][NEUTRAL] Uh, claim and um yeah and if you can just help, uh, put a note in the system because everything I do is just so complicated, you know, so I just figure it'll help if you put a note in the system so that if there's issues when I call back they'll understand why there's that difference of, you know, that 140 that you guys owe and not, you know, they're gonna build some huge random number of 1440.
[AGENT][NEUTRAL] So you might wanna reach out to them to let them know we do not have a claim on the file for 210. We don't have that claim yet, so you might wanna just let them know that.
[CUSTOMER][NEUTRAL] I mean 11:40.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alrighty, um, yeah, and you can just, uh, uh.
[AGENT][NEUTRAL] Is there anything else I can assist you with today, [PII]?
[CUSTOMER][NEUTRAL] No, if you can just put a note that I called today and um you know, and inquire on that so that, you know, and that it's uh that it's from that one procedure that was uh a session of three la laser um treatments.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Yes, I'll note your account.
[CUSTOMER][POSITIVE] All right, thank you, [PII]. I appreciate your.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][POSITIVE] Help. Have a wonderful weekend.
[AGENT][POSITIVE] Well, thanks for calling APL. You have a good day as well.
[CUSTOMER][POSITIVE] Thank you bye bye.
[AGENT][NEUTRAL] Mm bye.