AccountId: 011433970860
ContactId: 9f6e0946-6411-45ea-bd2a-ab1e74f68b4b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 566599 ms
Total Talk Time (AGENT): 254583 ms
Total Talk Time (CUSTOMER): 197799 ms
Interruptions: 0
Overall Sentiment: AGENT=0.1, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/28/9f6e0946-6411-45ea-bd2a-ab1e74f68b4b_20250328T19:51_UTC.wav
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[AGENT][POSITIVE] Thanks for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII], and about, I don't know, a month or so ago I received a notice, um, this is not a bill in the mail, and it was, um, stating that there was a check written and sent, but I don't know who got the check. Would you be able to tell me that?
[AGENT][NEUTRAL] Uh, sure. Was it, are you with the provider's office or is this for yourself?
[CUSTOMER][NEUTRAL] No, this is me personally I'm the claimant, but I never got a check so I just wanna verify.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, sure.
[AGENT][NEUTRAL] Um, do you have your policy number, [PII]?
[CUSTOMER][NEUTRAL] Uh, yes, it's 02550829.
[CUSTOMER][NEGATIVE] It just seems like nothing's ever covered. I go to the doctor so much.
[AGENT][NEUTRAL] Um, let's see, can, um, we'll look at that. Let's see. Can you verify your birth date for me?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Uh, what's a good callback number, [PII], just in case I lose you?
[CUSTOMER][NEUTRAL] Yeah, [PII].
[AGENT][NEUTRAL] Like
[AGENT][NEUTRAL] And just need to verify a few more pieces of info. What is your address?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] And then lastly your email address.
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][POSITIVE] OK, thank you so much.
[AGENT][NEUTRAL] OK, let's see, did, do you have a claim number for that or the check number?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I don't have that. I don't have that with me, um.
[CUSTOMER][NEUTRAL] I'm looking at a new claim and it wasn't covering so that just prompted me to take this with me to call and check on it so I apologize I don't have that with me.
[AGENT][NEUTRAL] Oh, no worries, let's see, um.
[CUSTOMER][NEUTRAL] Like I said, it's been a month or so ago, about a month and a half.
[AGENT][NEUTRAL] OK, let's see what I can look at.
[AGENT][NEUTRAL] Do you recall if it was for yourself?
[CUSTOMER][NEUTRAL] Uh, yes, it would be for myself.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] It looks like we received an outpatient claim.
[CUSTOMER][NEUTRAL] For my husband.
[AGENT][NEUTRAL] And we made a payment of 500 to the provider, so it looks like the claim was received from the.
[CUSTOMER][NEUTRAL] Oh you did it.
[AGENT][NEUTRAL] Yeah, to the provider, um.
[CUSTOMER][POSITIVE] Awesome.
[AGENT][NEUTRAL] So that would.
[CUSTOMER][NEUTRAL] Would it be better?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Was that Sutter Health, the provider?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] That was, um, that was for data service 12-2025 and that was for Sutter uh Gold Medical Foundation.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] OK, that explains that.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] I just have had two MRI's recently and I just, I'm, I don't know, it's just like nothing's ever covered.
[AGENT][NEUTRAL] Well, we did pick up the 500 for that. Let me see if we got was, did you have one after that?
[CUSTOMER][NEUTRAL] Oh, anyway, um,
[CUSTOMER][NEUTRAL] Had them both done on the same day.
[CUSTOMER][NEUTRAL] No, I had 2 done on the same day.
[AGENT][NEUTRAL] Oh, OK, let's see.
[CUSTOMER][NEUTRAL] So would they be treated separately? Because I, I know they treated me separately when I went in the same day.
[AGENT][NEUTRAL] Let me see what your benefit allows. It might be a $500 per day maximum.
[AGENT][NEUTRAL] Let me double check.
[CUSTOMER][NEUTRAL] Oh great, that would just be my luck.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Let's see.
[CUSTOMER][NEGATIVE] Because those stupid things are expensive.
[AGENT][NEGATIVE] I know they are very expensive.
[AGENT][NEUTRAL] Uh, give me just one moment, I'm gonna pull it up.
[CUSTOMER][NEUTRAL] I'm going to the neuros.
[CUSTOMER][NEUTRAL] Yeah. Mhm.
[AGENT][NEUTRAL] Yeah, it looks like $500 per occurrence, so that first MRI would have been an occurrence for outpatient services. So if you had it, you know, a second time in that day, it, it already paid the $500 for that occurrence on that date.
[CUSTOMER][NEUTRAL] So it goes by day, not by process?
[AGENT][NEUTRAL] Well, we only received, let me see, let me check another place.
[AGENT][NEUTRAL] Let me see here.
[AGENT][NEUTRAL] So you had 2 the exact same day was like [PII], [PII].
[CUSTOMER][NEUTRAL] No, they were, um, they did the first one and then they put an IV in me and did the second one and I don't know why they were done on the same day. I have no idea. I just think they saw that I needed them both and set me up that way.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] One was for my brain. I had a brain tumor removed a couple of years ago and the other one is for a growth in the roof of my mouth.
[CUSTOMER][NEUTRAL] So and that was a new thing that I was going through.
[AGENT][NEUTRAL] OK, let me see, let me see what they submitted that might figure out what's going on. Maybe they didn't submit the second one. Let's see.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] The second one was Doctor [PII], which is an ear, nose, and throat doctor, which is different than my neurosurgeon.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, let's see
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Pulling this up to see what we've got.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Um, let's
[AGENT][NEGATIVE] Sorry, system's running just a bit slow.
[CUSTOMER][POSITIVE] Oh, I'm at your mercy, no worries at all.
[AGENT][NEUTRAL] OK, so it does look like we just received on[PII]
[AGENT][NEUTRAL] Um, let me see, let me see.
[CUSTOMER][NEUTRAL] Oh, is it with Doctor [PII]?
[AGENT][NEUTRAL] That is for um.
[AGENT][NEUTRAL] Doctor
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] Does that sound familiar?
[CUSTOMER][NEUTRAL] So I don't know who that is.
[AGENT][NEUTRAL] Yeah, part of the Sutter Gold Foundation. Let me look up also, let me look one other thing up because let me see how the policy defines occurrence.
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, let's see.
[AGENT][NEUTRAL] And that'll tell us if if the other one we can see if they can file that.
[CUSTOMER][NEUTRAL] Maybe they did that so that they
[CUSTOMER][NEUTRAL] It's an insurance thing and you guys are helping each other out and they wouldn't have to pay me or pay for it. I'm sorry, I'm being negative. I apologize.
[AGENT][NEUTRAL] Uh,
[AGENT][NEUTRAL] No, I, I understand. I, it can really start to stack up, so I totally understand. Um, OK, so here, here's how the plan, the policy defines occurrence. It's the treatment for the same or related condition unless separated by a period of 90 days.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So if you, if you're treated for the same or related condition,
[AGENT][NEUTRAL] Under 90 days, that's an occurrence.
[AGENT][NEUTRAL] So it would have to be something completely separate. So, but you said one is for, one was for the roof of your mouth and then the other was for the brain?
[CUSTOMER][NEUTRAL] Um, yeah, I had a brain tumor removed 2 years ago, so I have to go every year now for the rest of my life, um, for a brain, uh, MRI. And then this other one was for a growth in the roof of my mouth, which we didn't know what it was for, or what it's about, and I haven't even gotten the results back on that yet, so.
[AGENT][NEUTRAL] OK, so that's, that's.
[CUSTOMER][NEUTRAL] They're two separate docs.
[AGENT][NEUTRAL] Two separate doctors or two unrelated things, so.
[AGENT][NEUTRAL] Looks like that that could be um and let me give you a quick disclaimer, this isn't a guarantee of payment it's just a basic outline of your policy um that could be if they're not related that would under the policy definition those would be separate things so the one that I have on file like I said it's got.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The referring physician was Doctor [PII]. Is that?
[CUSTOMER][NEUTRAL] Oh, that's for the roof of my mouth.
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, that's the roof of your mouth. OK, this is the one that we have on file.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] So I got.
[CUSTOMER][NEUTRAL] So you don't even have my brain one yet.
[AGENT][NEUTRAL] No, we don't have that one, so.
[CUSTOMER][POSITIVE] And that's funny, that's the first one they did.
[AGENT][NEUTRAL] Yeah, so
[CUSTOMER][NEUTRAL] And [PII] was the 2nd 1.
[AGENT][NEUTRAL] I would, I would give them a call and see if they can get that submitted for you, um, because like I said, as, as long as that's, it's a different part of the body, it's gonna be a different diagnosis, that's gonna be an unrelated medical condition, so.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, all right, well you, you help, you've helped me a lot. I appreciate that um you have a wonderful day and thank you for your help.
[AGENT][POSITIVE] OK, well, thank you for calling APL and I hope you have a great weekend.
[CUSTOMER][NEUTRAL] You too, [PII]. Bye-bye.
[AGENT][NEUTRAL] Bye.