AccountId: 011433970860
ContactId: 96d94991-9688-4678-995f-b8d9a31fcf5a
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 681520 ms
Total Talk Time (AGENT): 398320 ms
Total Talk Time (CUSTOMER): 242622 ms
Interruptions: 6
Overall Sentiment: AGENT=0.9, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/14/96d94991-9688-4678-995f-b8d9a31fcf5a_20250414T15:12_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][POSITIVE] Good, how are you?
[AGENT][NEUTRAL] I'm so sorry it kind of cut out. What was that?
[CUSTOMER][NEUTRAL] So how are you today?
[AGENT][POSITIVE] I am doing well. How are you?
[CUSTOMER][NEUTRAL] OK thank you. I'm wonderful, Ms. [PII]. I have a question regarding our plan and how it works necessarily so I um have submitted claims and I've submitted claims where I have paid myself these co-payments or payments to to the provider and then I see here that APL is paying the provider as well.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] Are they supposed to pay the provider or pay or reimburse me back?
[AGENT][NEUTRAL] So it in short it depends on who files the claim so if the provider were to be the ones to file the claim we would send the payment to them if you file a claim we would send that payment to you and if there was an amount that you paid and then we had also paid the provider, it could be specific things that may not have been covered under your policy um that you would have to pay out of pocket for for like a copay or anything like that but if you'd like we can get that pulled up uh just to verify all of that.
[CUSTOMER][NEUTRAL] Yeah. Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Yeah, please, please, thank you.
[AGENT][POSITIVE] Absolutely. What was your name?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And then [PII], can I get a good call back number from you in case we're disconnected?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] Thank you, do you have your policy number?
[CUSTOMER][NEUTRAL] Yes, it's 02497912.
[AGENT][POSITIVE] All right thank you one moment.
[AGENT][NEUTRAL] Alright, and then [PII] just gonna verify some information really quick. Uh, can I get your date of birth, please?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you and then can I get your mailing address?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Perfect. Last thing I need is the email address we've got on file for you. uh, looks like it's a Yahoo account.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][POSITIVE] Got you thank you so much for verifying all of that. OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So, let's see, I do see, let's take a look here.
[AGENT][NEUTRAL] So just looking at yours uh we've only got one claim that we did uh pay on um and that was from a provider a provider did file that claim.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And I do see that you have filed several.
[CUSTOMER][NEUTRAL] Was that the ending now?
[AGENT][NEUTRAL] Uh, let me, let me check that. Let's see.
[AGENT][NEUTRAL] Yes, uh, date of service was [PII] and so we paid a benefit of $50 yes.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Yeah, so that was a co-payment.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] And you're saying that you paid that out of pocket?
[CUSTOMER][NEUTRAL] Right, and that's, that's something.
[CUSTOMER][NEUTRAL] Yes, ma'am. Yes, and I submitted the receipt.
[AGENT][NEUTRAL] I would get both of them then mhm.
[CUSTOMER][NEUTRAL] So then, OK, so then I just wanna know how, what, uh-huh, uh-huh.
[AGENT][NEUTRAL] So if we set payment to them.
[AGENT][NEUTRAL] I'm sorry, I'm sorry, I don't mean to keep interrupting you, um, so, OK, so we did pay that, uh, payment to them that was the only payment that we've made, uh, so far for you so if you made that payment and then I would definitely get with your provider um I can give you this uh claim information um just to let them know you know you need that money back they need to give that back to you since we paid that benefit.
[CUSTOMER][NEUTRAL] It's OK.
[CUSTOMER][NEUTRAL] So I need to speak to Aetna, my insurance company.
[AGENT][NEUTRAL] Whoever you paid, so if you paid uh the provider, the doctor's office or yes, yes, um, then they've got double payments you know so you definitely need to get that back.
[CUSTOMER][NEUTRAL] O N D
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][POSITIVE] Got you, so I need to speak to them about that. OK, that's gonna be interesting.
[AGENT][NEUTRAL] Yes, and if you'd like, I can give you, uh, well, I can give you the claim number and of course you know if there's confusion they can give us a call. We talk to providers all the time. um, if it's easier you can give us a call while you're there, um, so um I've got the claim number if you'd like that for your records.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, I know I have it here. I have it here as well because I'm in my APL account.
[AGENT][POSITIVE] OK, perfect. OK, awesome, yes, so yeah, that is absolutely correct, um, so if you paid that you are owed that back.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, and then now for my daughter, [PII]'s um
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Let's take a look here. OK, so I've only got one claim on file for [PII]. I've got and we did pay that benefit that was also $50 for [PII] Children's, uh, pediatric.
[CUSTOMER][NEUTRAL] Account
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Is that a similar situation? OK.
[CUSTOMER][NEUTRAL] Yes, so that one I didn't pay. They, they submitted, well, no, that one I gave them my, my card and then they went ahead and, and sent over the payment.
[AGENT][NEUTRAL] Yes.
[AGENT][POSITIVE] Awesome, yes, so that has been taken care of.
[CUSTOMER][POSITIVE] And then I also, perfect.
[AGENT][NEUTRAL] Go ahead, I'm sorry.
[CUSTOMER][POSITIVE] Perfect. I, and I have a question regarding this claim that I submitted. So, the claim num, let me see, I'm sorry.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] No, you're fine.
[CUSTOMER][NEUTRAL] Yeah, claim number is 33582104.
[AGENT][NEUTRAL] OK, let me get that one pulled up.
[CUSTOMER][NEUTRAL] So I just wanna know if I'm doing this correctly or not.
[AGENT][NEUTRAL] Absolutely and it can be very confusing as to what information we need so let me take a look here.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Oh, this is actually stating that it's a duplicate claim.
[AGENT][NEUTRAL] Let me look at that.
[AGENT][NEUTRAL] 104 so that was for.
[CUSTOMER][NEUTRAL] Maybe I submitted it twice or something.
[AGENT][NEUTRAL] That's what it says. Let me try to find the original [PII]. Let's see.
[AGENT][NEUTRAL] Yes, yes, OK, so I did find the original claim. Give me just a moment, let me take a look at those notes.
[AGENT][NEUTRAL] OK, so yes we are missing some information and I can give you this claim number too if you'd like uh just so you see the original one was uh the one ending in 757.
[CUSTOMER][NEUTRAL] Uh, hold on, give me one second.
[CUSTOMER][NEUTRAL] The original claim is
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] What 757 that's the original claim?
[AGENT][NEUTRAL] Yeah it's uh 356-475-7. Those are the same items uh that were on that other claim number that you gave me. So in short, and this seems to be we're missing uh most of this information, but um whenever you're ready if you'd like to write it down I'll tell you just exactly what we need for claims.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, give me one sec.
[AGENT][NEUTRAL] Let me know when you're ready, sure.
[CUSTOMER][POSITIVE] OK, I'm ready.
[AGENT][NEUTRAL] OK, so we would need the itemized statement.
[AGENT][NEUTRAL] That shows
[AGENT][NEUTRAL] Diagnosis and procedure codes.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then we would need the primary explanation of benefits.
[CUSTOMER][NEUTRAL] I've said that before.
[AGENT][NEUTRAL] So yeah, and essentially.
[CUSTOMER][NEUTRAL] So that has to be submitted every time?
[AGENT][NEUTRAL] Absolutely, um, so that is, as this is your secondary medical policy, it is very dependent on uh your primary, so we have to see that they paid something because if they, if they're not willing to pay anything this policy can't. So, um, and that's information, all of that, the the auto my statement and the EOB you can get that all from wherever you or [PII] went for treatment, they will have all of that right there so um just.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] So I see here, I, I'm sorry, I don't mean to interrupt you. I'm so sorry.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] No, no, no, you're fine. You're OK, go ahead.
[CUSTOMER][NEUTRAL] Oh, OK, so this is where you are explanation of benefits.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] This is
[CUSTOMER][NEUTRAL] OK, this is you all telling me that I you all need.
[CUSTOMER][NEUTRAL] That information.
[CUSTOMER][NEUTRAL] I'm trying to see where it is that I uploaded that.
[AGENT][NEUTRAL] Well, I did see one as well stating that we were missing the uh diagnosis code.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And so that's what we need all of that together the itemized statement that shows those codes and then the primary explanation of benefits.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK, and then I can get the primary explanation of benefits where again?
[AGENT][NEUTRAL] From wherever you went for treatment, whatever uh provider facility, um, hospital, they will have that information because again, it's just showing what they contributed um to that cost.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] It.
[CUSTOMER][NEUTRAL] This.
[CUSTOMER][NEUTRAL] Oh, but not, not the, the itemized. I meant the primary benefits. Is that coming from the actual doctors? Oh, it's coming from the, oh, OK.
[AGENT][NEUTRAL] Yeah yeah the provider will have that as well, mhm.
[AGENT][POSITIVE] They will have that as well because again that's showing what they what your primary paid them so they will absolutely have that.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Got you.
[CUSTOMER][NEUTRAL] OK. OK. Well, thank you so much. OK, and then I guess let me ask this one more question. When, whenever I, whenever I go to a doctor's office, my daughter, for instance, or anything like that, like for instance, she's there right now and she paid a $10 co-payment.
[AGENT][POSITIVE] You are very welcome. Yes.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Now, her, when, when they get to the doctor's office, are they supposed to show the gap as well, or they already, if they already have that on file, they should know.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] I would absolutely just kind of make it um to where, wherever you or [PII] goes for any sort of medical treatment is to present them with both your primary and this uh card as well. The bad thing is sometimes it is going to be up.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][MIXED] To each provider some really don't like messing with any sort of secondary or supplemental insurance at all um but that doesn't mean that you can't file those claims it's just a bit more of a headache for you so it'd be better if they did of course um but otherwise yeah I would.
[CUSTOMER][NEUTRAL] Right, like, for instance, my daughter's pediatric, my daughter's pediatric office, they, they couldn't find a number to, to add on or anything like that from the card that I gave them, so they just, they didn't um accept it.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] If that happens again or anything if there's any kind of confusion, I would have them give us a call um because it's it's possible they say they still may not again it's up to them, but I think it's worth a shot we might be able to direct them and give them any information they might need over the phone just so it's less for you to have to worry about, you know.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK. Well, thank you so much.
[AGENT][NEUTRAL] Yeah, was there anything else I could help you with, [PII]? I know that was quite a bit of information.
[CUSTOMER][POSITIVE] No, that's it. Thank you.
[AGENT][POSITIVE] Alright, yeah, thanks for giving us a call. I hope you have a great rest of your day.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][POSITIVE] Thank you bye bye.