AccountId: 011433970860
ContactId: 8e0032ce-6c78-4a43-b879-adb0e12e89ef
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 875969 ms
Total Talk Time (AGENT): 369410 ms
Total Talk Time (CUSTOMER): 360902 ms
Interruptions: 5
Overall Sentiment: AGENT=0.6, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/28/8e0032ce-6c78-4a43-b879-adb0e12e89ef_20250428T17:32_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII], my name is [PII]. Um, I'm calling because I wanted to inquire about a
[CUSTOMER][NEUTRAL] Claim for one of my son's uh surgical procedures back in January. And um I just talked to the uh hospital and they said that they had sent something over, um, but I hadn't gotten any updates um since then. And when I checked the uh online claims with your, uh, with your business, I didn't see anything specifically for
[CUSTOMER][NEUTRAL] Um, that amount, so I, I just kind of wanted to get clarification on whether or not you guys got the correct claim or the correct amount and um to see if we can kind of figure this out.
[AGENT][NEUTRAL] OK, sure, [PII], so.
[AGENT][NEUTRAL] OK, so you're wanting to check to see if we've received a claim for your son, is that correct?
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] Yes, sir. I can help you with that. And [PII], what is your last name?
[CUSTOMER][NEUTRAL] Uh [PII]
[AGENT][POSITIVE] OK, thank you. And what is a good callback number for you please?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. And what is your policy number?
[CUSTOMER][NEUTRAL] Uh, the policy number is.
[CUSTOMER][NEUTRAL] 02473335 ML.
[AGENT][NEUTRAL] OK, that was 23. Is that correct? Or 3?
[CUSTOMER][NEUTRAL] Uh, so it was 024.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 733.
[CUSTOMER][NEUTRAL] 35 ML.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, and any information that I do provide for you today would be a verification of benefits and not a guarantee of payment. I will have to verify several things with you first for security, Caesar. So first off, if you could please verify your date of birth and then your son's name and date of birth.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So my date of birth is [PII]. My son's name is [PII], and his date of birth is [PII].
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And then also your home mailing address please.
[CUSTOMER][NEUTRAL] Home mailing address is [PII].
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] [PII] sorry.
[AGENT][NEUTRAL] That's OK. And the phone number that we show on file for you is the same as the one that you gave me, so that is your best contact number, is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, thank you. And then lastly your email address please.
[CUSTOMER][NEUTRAL] So my email address is my last name, [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] OK, thank you very much.
[AGENT][NEUTRAL] Alright, and what is the date of service and build amount that I'm looking for for him for Mateo?
[CUSTOMER][NEUTRAL] The date of service is [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It was for ear tube placements.
[CUSTOMER][NEUTRAL] Uh, at Memorial Regional and the estimated amount is about 3300.
[CUSTOMER][NEUTRAL] About 3300.
[AGENT][NEUTRAL] So you don't have the specific bill amount?
[CUSTOMER][NEUTRAL] Um, no, I do not.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And you're looking for the facilities charge, is that correct?
[CUSTOMER][NEUTRAL] Um, I'm looking for, uh, a, um, I guess the claim that they say that they sent, um, over for that approximate amount. The only other claim that I have related to that.
[CUSTOMER][NEUTRAL] Um, service date, uh, was for $300.
[CUSTOMER][NEGATIVE] Um, and that didn't seem right.
[AGENT][NEUTRAL] That you filed.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, no, I didn't file anything.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Cause this shows that the benefit.
[AGENT][NEUTRAL] OK, so I'm just gonna have to look at um.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Let me see if I can find.
[AGENT][NEUTRAL] Cause this, from what I can tell, it looks like we.
[CUSTOMER][NEUTRAL] A quick explanation of benefits here.
[AGENT][NEUTRAL] So it looks like we received a claim. From what I can tell, it appears that it would have been something, the benefit shows that it was paid to you.
[AGENT][NEUTRAL] The $300.
[AGENT][NEUTRAL] And that was on a charge of 3 $3,665.
[CUSTOMER][NEUTRAL] $300.
[AGENT][NEUTRAL] Was that bill amount for that data service?
[AGENT][NEUTRAL] And the benefit was issued. This was done back in January.
[AGENT][NEUTRAL] It was processed on [PII].
[AGENT][NEUTRAL] And it was a direct deposit to you.
[CUSTOMER][NEUTRAL] Hold on a second.
[AGENT][NEUTRAL] It wasn't a check issued it was a direct deposit, that is correct because this was an outpatient.
[CUSTOMER][NEUTRAL] But only for 300?
[AGENT][NEUTRAL] Um, procedure and on your excuse me, on your supplemental policy, the maximum benefit per calendar day for covered outpatient services is 300.
[CUSTOMER][NEUTRAL] Mm, OK.
[AGENT][NEUTRAL] Now, it looks like that we had received another, let me go back to the data service. Give me just a moment.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] There were claims, there was a claim submitted by the facility after that was processed, but it did get denied.
[AGENT][NEUTRAL] Um, let me pull that remark.
[AGENT][NEUTRAL] We did receive a claim from Memorial Regional Hospital.
[AGENT][NEUTRAL] But again, that claim was denied and that's under claim.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] If you want me to give you the claim numbers, the one you should see where we paid the benefit to you is claim number 355.
[AGENT][NEUTRAL] 3073.
[CUSTOMER][NEUTRAL] OK, it's just that I don't, I don't I don't remember ever getting the text message that I not that I'd normally get for notification.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, about that payment going out, so if it went through.
[CUSTOMER][NEUTRAL] Um, it just, it just went through as a regular payment and I didn't even realize that it came through APL.
[AGENT][NEUTRAL] Uh-huh, sure.
[CUSTOMER][NEUTRAL] Um, so this whole time I didn't even realize, uh, that that payment had come to me, which I'm not really sure why it came to me because it usually goes out to.
[CUSTOMER][NEUTRAL] Um, the hospital.
[CUSTOMER][NEUTRAL] Um, and you said that that came through on [PII]?
[AGENT][NEUTRAL] Well, that's when we processed it.
[AGENT][NEUTRAL] Uh, OK. I was in, OK, so the claim, let me just finish telling you about this claim since I have it pulled up that we received after that one that we paid and we did deny it as a duplicate.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I've previously submitted it because benefit payment was issued to the insured, being you. That's the remark on claim 3554994.
[AGENT][NEUTRAL] Now the claim in which we paid.
[CUSTOMER][NEGATIVE] Oh, this is gonna be problematic now.
[AGENT][NEUTRAL] We did receive an uploaded claim through the online service center on [PII].
[AGENT][NEUTRAL] And that is the one that was processed on the [PII].
[AGENT][NEUTRAL] With payment to you.
[AGENT][NEUTRAL] In the form of a direct deposit.
[CUSTOMER][NEUTRAL] OK, um.
[AGENT][NEUTRAL] And that was under claim number 3553073.
[CUSTOMER][NEUTRAL] OK, so sometime after.
[CUSTOMER][NEUTRAL] that
[CUSTOMER][NEUTRAL] Procedure. I should have a direct deposit.
[CUSTOMER][NEUTRAL] For $300 is what you're saying, correct?
[AGENT][NEUTRAL] Yes, sir, because let me just look at the calendar.
[AGENT][NEUTRAL] To see what date that fell on.
[AGENT][NEUTRAL] OK, so the claim was processed on January it went through our nightly processing on [PII]. That was a Friday, so you would not have, you would not have seen it in your account. These are until maybe.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Typically it takes 2 to 3 business days. So it would have been, I would say sometime that week of the of the [PII] in January, probably the [PII]-ish.
[CUSTOMER][NEUTRAL] OK. No, I found it. I found it.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] No, I found it. I found it. It's just, it kind of complicates things because if I would have known that it was, it was coming as a, as a deposit, I would have put that money aside, because normally it just gets paid directly.
[AGENT][NEUTRAL] Maybe. 00, OK.
[CUSTOMER][NEUTRAL] To the facility, uh, that's that's giving the claim.
[AGENT][NEUTRAL] Well, when, when you file it, yes, so when you file it, it's going to be to whoever files it unless.
[AGENT][NEUTRAL] It has got a different assignment of benefits on the information.
[AGENT][NEUTRAL] So it's if we have received the facilities claim.
[CUSTOMER][NEUTRAL] Well, if I, if I filed it, it was probably because they were asking for an an EOB.
[AGENT][NEUTRAL] And then you provided that before they did.
[CUSTOMER][NEUTRAL] So, I didn't.
[AGENT][NEUTRAL] Probably could have been the case.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] OK, um, I, I still didn't know that if I provided the EOB that it was gonna be paid out to me. So the, the, the problem is that that money, you know, back from, from January is done and gone, and I still have a co-payment and another $300 that I need to come up with now, um.
[AGENT][NEUTRAL] Sure, OK.
[CUSTOMER][NEUTRAL] So, OK.
[CUSTOMER][NEUTRAL] Alright, so I'm gonna have to call them back.
[CUSTOMER][NEUTRAL] And tell them that uh that the payment was issued to me because they're still waiting for it.
[AGENT][NEUTRAL] Yes, sir. And they received the explanation of benefits stating that it had been paid to you, but we don't tell them how much, just the, the benefit was paid to you.
[CUSTOMER][NEUTRAL] Right, um, so they're, they're under the impression that, um, they got a they got a letter saying that the zero patient responsibility, but that's not the case.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Well, we don't determine patient responsibility on any level, even if they have filed it with us not being a major medical carrier, that's always up to the provider as to how they handle any patient responsibility. Oh, OK. OK.
[CUSTOMER][NEUTRAL] No, I unders I understand all that. I understand all that. It's just that all of this got confused when
[CUSTOMER][NEGATIVE] The payment went out to me and I didn't get notified, and they're still waiting on the payment for whatever reason. So, I have to clarify all of this when I feel like I shouldn't have to, but um it falls on me now.
[CUSTOMER][POSITIVE] Uh, you know, to get everything, uh, coordinated and, and updated correctly.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] But you did locate that deposit that was issued.
[CUSTOMER][NEUTRAL] I, I did. It, it would have been nice to know that it came, it came to me, but um, yes, I did. I found it. It, it just complicates things.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Because like I said, I, I have to be the one to correct all of this now.
[AGENT][NEUTRAL] Yes, sir. And we also mailed that explanation and then you should have received it, it, which is exactly like what you see in your portal, but you should have received that in the mail as well.
[CUSTOMER][NEUTRAL] So, OK.
[CUSTOMER][NEGATIVE] Yes, I received I received the I received the paper that says that it was, it was maximum benefit. I did, I did receive that. But like I said, because I normally, because the nor the paper normally says that it gets paid out to the other person. I didn't look at it, um, again, that was my assumption, but I also was not notified that I was getting the payment directly.
[AGENT][NEUTRAL] Oh, OK. OK.
[CUSTOMER][NEUTRAL] Just based on how it's worked in the past.
[AGENT][NEUTRAL] Sure. I understand.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] But when you provided the documentation, that's why the payment was issued to you.
[CUSTOMER][POSITIVE] OK, well, thank you.
[CUSTOMER][NEUTRAL] Well, I understand that now so moving forward I'll make sure that I, I know that if I provide documentation I'll be the one receiving the payment.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] If that is, yes, typically that is how that whoever provides us with what we're needing would be the one to receive the payment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] Yes, it does say here direct deposit, my account number.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Um, yeah, OK. Thank you.
[AGENT][POSITIVE] OK. Well, you're very welcome. So is there anything else that I can help you with today?
[CUSTOMER][NEGATIVE] No, no thank you.
[AGENT][POSITIVE] OK, well then, thank you, [PII] for calling APL and I hope you have a very nice afternoon.
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][POSITIVE] Thank you. Bye-bye.