AccountId: 011433970860
ContactId: 8ce84946-2ebb-46f1-9450-0ad25814301f
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 862830 ms
Total Talk Time (AGENT): 276179 ms
Total Talk Time (CUSTOMER): 518255 ms
Interruptions: 4
Overall Sentiment: AGENT=0.4, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/27/8ce84946-2ebb-46f1-9450-0ad25814301f_20250127T20:09_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] APL, this is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Um, good morning or good afternoon. You said your name's [PII]?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Oh [PII], OK. [PII], hi. um I am calling because I have uh several bills, um, that I had, you guys are my were my secondary up until November, and I am getting bills now that um was happened to be like in July and other things and I'm pretty sure they probably did not go through APL.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] So is that something you can check for me if I have information?
[AGENT][NEUTRAL] OK. Uh, give me your name.
[CUSTOMER][NEUTRAL] I have several different ones. My name is [PII] The policy, it's under my my hus it was under my husband's insurance, but the policy, the group, uh, policy number 019641777.
[AGENT][NEUTRAL] OK, your name
[AGENT][NEUTRAL] And the policy number?
[AGENT][NEUTRAL] I get phone number in case we're disconnected?
[CUSTOMER][NEUTRAL] Um, phone number [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] And [PII], what's your date of birth?
[CUSTOMER][NEUTRAL] My date of birth is [PII].
[AGENT][NEUTRAL] And are the claims for you?
[CUSTOMER][NEUTRAL] Um, most of them are for me. There's one for my husband that he thinks he does owe the 40 because that one was in February last year, so he thinks he might.
[AGENT][NEUTRAL] And what are your date of service?
[CUSTOMER][NEUTRAL] So my dates of service, um, [PII].
[CUSTOMER][NEUTRAL] [PII] and that was with [PII]. I have voucher numbers or or numbers if you need.
[CUSTOMER][NEUTRAL] So that was a $40.01 [PII], um, with
[CUSTOMER][NEUTRAL] [PII] and that would be a $40.01.
[CUSTOMER][NEUTRAL] Am I going too fast?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK. [PII], and that was with Malibra, but that was like with um different panels. I had a lot of different health issues last year. So I had to do a bunch of stuff. And that was [PII] and
[CUSTOMER][NEUTRAL] Yeah, and that was for 8442 was the amount that they're asking for.
[CUSTOMER][NEUTRAL] And then the last one of mine is for um
[CUSTOMER][NEUTRAL] Well, it says 4:18, but the, then the other one says, and I'm pretty sure it's 64 um 24. I had uh a cyst removed off my back from Galaska.
[CUSTOMER][NEUTRAL] And that one says $563.40.
[AGENT][NEUTRAL] OK, so are you asking if the provider submitted the claims or did you submit the claims to us?
[CUSTOMER][NEGATIVE] I'm asking, I guess if the provider, I mean, I have a feeling because I called back in June, cause I had a ton of bills. I was in the, I was in the hospital. I had a mild atypical heart attack, and I've got, I've had a lot of other things go on and stuff like that. So, I mean, I'm getting these bills from the provider and what we found out like in August when I called you back, when I called you guys was that a ton of claims weren't submitted.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And they got all cleared up because, so I'm just trying to figure out how to get the secondary.
[CUSTOMER][NEUTRAL] To pay for it because I had secondary at the time.
[AGENT][NEUTRAL] OK. And so,
[CUSTOMER][NEUTRAL] Or I had you guys at the time.
[AGENT][NEUTRAL] For the [PII] state of service, did you say that was for lab work?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] Did you receive explanation of benefits from American Public Life?
[AGENT][NEUTRAL] Which would tell you how the claim was processed.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] I don't think so for any of this. I mean, I
[CUSTOMER][NEUTRAL] I really don't think so.
[AGENT][NEUTRAL] Yeah, they're mailed automatically when the the next business day after the claim is processed, uh, they would have been addressed to the policyholder which is your spouse.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, the [PII] data service was that for an office visit?
[CUSTOMER][NEUTRAL] [PII], yes.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So [PII] was an office visit. [PII] was an office visit. [PII] was, um, all these panels and stuff. I had, uh, you know, like uh blood work. And then this other one is from, I believe it's from [PII] where they took
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I pretty much did surgery and biopsy and took something off my back.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And that was the biggest one which was $563.40.
[AGENT][NEUTRAL] And so the [PII] data services, would that be like your surgeon's charge?
[CUSTOMER][NEUTRAL] [PII]?
[AGENT][NEUTRAL] I'm sorry, I meant [PII]. Yeah, I meant [PII].
[CUSTOMER][NEUTRAL] [PII], um it says E X C B 9 L E S M R G N. I don't know, I've got numbers by it and it says $1052.
[AGENT][NEUTRAL] OK. OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And that's the only because on this one, I don't see where there's anything.
[CUSTOMER][NEUTRAL] Else there is another date on it, um, from April, but that looks like it was paid so this has got to be from [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Where it says 10052 and only.
[CUSTOMER][NEGATIVE] The only thing that was 500 and it looks like 48 paid or something. I don't know. I'm kind of confused.
[AGENT][NEUTRAL] OK. So the [PII].
[AGENT][NEUTRAL] OK, the [PII] data service was it from Optumare Colorado Springs?
[CUSTOMER][NEUTRAL] Yes, it was um provider Gaska Dermatology.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, on the document that you have, does it show the billed amount? Because I think what you're giving me is what's due. So is there a billed amount on there?
[AGENT][NEUTRAL] Total bill amount?
[CUSTOMER][NEUTRAL] It says amount due upon receipt.
[AGENT][NEUTRAL] So is it just showing a balance due or does it show the uh uh initial charge that was billed?
[CUSTOMER][NEUTRAL] is what
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Um, well, the initial charge is it do need to, um.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] This is just on the first piece of paper like all of them say that they're they're due, the amounts I gave you, but that one says insurance is it total.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, it has a
[CUSTOMER][NEUTRAL] A bunch of different um things, let's say insurance payment, insurance adjustment, insurance payment, insurance transfer, insurance transfer.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. Let me see what I can find. Give me one second.
[CUSTOMER][NEUTRAL] And I'm pretty sure that because I had everything, I mean we paid an exorbitant amount of money last year, well, not an exorbitant, but I mean we, I, we, I'm pretty sure we met our deductible with everything.
[AGENT][NEUTRAL] OK, and you
[AGENT][NEUTRAL] OK. And you said that you were treated by uh [PII]?
[CUSTOMER][POSITIVE] Yes, sir. Yes, ma'am. I'm sorry.
[AGENT][NEUTRAL] OK. No, that's OK. So, I do.
[CUSTOMER][NEUTRAL] I do.
[AGENT][NEUTRAL] That's OK.
[CUSTOMER][NEUTRAL] Sorry, [PII].
[AGENT][NEUTRAL] So I do show this
[CUSTOMER][POSITIVE] You need a good laugh anyway.
[AGENT][NEUTRAL] So I do show the [PII] charge, um, there was nothing payable on this claim because the maximum outpatient benefit is exhausted and I believe that's gonna be the same for all of these dates of service that you are that you've given me.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] Um, let's see.
[CUSTOMER][NEUTRAL] So you guys only pay a certain percentage or is that what you?
[AGENT][NEUTRAL] Dollar amount.
[AGENT][NEUTRAL] Dollar amount per calendar year for any outpatient service.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And under your policy, give me a second.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And that, that was outpatient. That's probably the difference between, cause so if I had been hospitalized, you wouldn't, you would have paid it. Is that right, Pa?
[AGENT][NEUTRAL] Let me verify your benefit. Yeah, your maximum outpatient, actually your inpatient and outpatient benefit is combined. However, your maximum outpatient benefit is up to $4000.
[AGENT][NEUTRAL] Um, per calendar year and let me see, these were for 2024.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So you had outpatient and inpatient services in [PII]?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, so since the benefit is combined, um, your outpatient inpatient is $5000 so the maximum payout benefit would not exceed the $5000 figure. So let me calculate this real quick.
[CUSTOMER][POSITIVE] OK, I appreciate it.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Right, so between your outpatient and inpatient services it exhausted the $5000 combined maximum. So once that the combined maximum was met, anything after that was denied as the maximum benefit is exhausted and on all of these claims that you gave me, the benefit maximum max was already met.
[AGENT][NEUTRAL] No more benefits were available at the time we received the claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So all of that what you're saying is they did go through you guys that you um.
[AGENT][POSITIVE] Yes, they did submit them to us for processing, yes ma'am.
[CUSTOMER][NEUTRAL] Oh, OK, that's, that's a good thing because like I said when I called this summer, there was tons of bills that had not gone through. So I probably do owe.
[AGENT][NEUTRAL] Mhm. Right.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEGATIVE] All of these bills.
[CUSTOMER][NEUTRAL] Is what you're saying.
[CUSTOMER][NEUTRAL] Even the $40 and the $84 and stuff like that, the 4 different ones.
[AGENT][NEUTRAL] Yeah, which we can't.
[AGENT][NEUTRAL] You know, from looking at the remark code, your maximum outpatient inpatient benefit is exhausted so we couldn't pay anything else because we paid the maximum.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK. OK. Well, I appreciate you checking and everything.
[AGENT][POSITIVE] Oh, you're welcome.
[AGENT][POSITIVE] You're welcome. Now, that's for you.
[CUSTOMER][POSITIVE] Um, it's always a good.
[AGENT][NEUTRAL] Now, did you want me to check on the other dependents or your spouse?
[CUSTOMER][NEUTRAL] Yes, yeah, there was one for my spouse too while we're on and let me look and see which one that was.
[CUSTOMER][NEUTRAL] So that is just for me individual. So there was one for him that said that we just received um.
[CUSTOMER][NEUTRAL] His would have been, you need the date, correct?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, [PII].
[CUSTOMER][NEUTRAL] Um, 2 last year.
[CUSTOMER][NEUTRAL] And it was [PII] and that was a $40.01.
[AGENT][NEUTRAL] So was it an office visit or was it a well checkup visit or both?
[CUSTOMER][NEUTRAL] That was a periodic preventive medicine and then
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I guess, oh, it only says one it says something about hemoglobin and systolic blood or something like that. So it was a periodic preventive medicine appointment.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so we did receive this claim as well.
[AGENT][NEUTRAL] Um, the office visit, um, was denied is not covered by this policy.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Uh, wellness services, there's one wellness code on here that was not covered because wellness is not covered by the policy and then the three other codes listed.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, the, it cites that, uh, your major medical, a major medical carrier did not pay those, they denied them. And so,
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] Um, when they're denied by the major medical carrier, this policy does not cover, um, the charges either.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK. Well, at least we're fine figuring it all out. And then before I started paying because, you know, a lot of times you pay stuff you don't have to pay. And then, and that's what I found out, that's what I found out in August when I was talking to somebody from your office. I was like, I don't understand why I'm getting tons and tons of bills, but they, they did help me out and you have helped me out and everything, and I appreciate it.
[AGENT][NEUTRAL] Right, right.
[AGENT][NEUTRAL] Right. That is, that is true.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] All right.
[AGENT][POSITIVE] Oh, you're welcome, [PII]. Did you have any other questions?
[CUSTOMER][POSITIVE] That was it. I appreciate you a lot. OK. Thank you very much. Bye.
[AGENT][NEUTRAL] All right.
[AGENT][POSITIVE] All right. You're welcome. Thank you for.
[AGENT][POSITIVE] Thank you for calling ATL. Have a good day.