AccountId: 011433970860
ContactId: a933cd11-c5cc-4439-b0e3-3cb428d6717f
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1550160 ms
Total Talk Time (AGENT): 370422 ms
Total Talk Time (CUSTOMER): 587114 ms
Interruptions: 1
Overall Sentiment: AGENT=0.1, CUSTOMER=-0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/10/a933cd11-c5cc-4439-b0e3-3cb428d6717f_20250310T18:31_UTC.wav
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[CUSTOMER][NEUTRAL] Because the results of the test were inconclusive anyway.
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII], and I'm calling about my daughter and then I have on the line, um, one of the billing, um, the one of the ladies from the billing office of one of her tests that she had done, um, so I, um, what information do I need to give you so we could take a look at it before I tell you.
[CUSTOMER][NEUTRAL] [PII], I can.
[CUSTOMER][NEUTRAL] I think I no I'm sorry, I thought I had a call reference number but it looks like a date is is that your call reference the name and date?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Usually we give a name and a date, yeah.
[CUSTOMER][NEUTRAL] OK, I have [PII].
[CUSTOMER][NEUTRAL] T
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Do we have a claim number or a policy number, we can start there?
[CUSTOMER][NEUTRAL] Yes, hold on, because I, if you need that I just have to look it up.
[CUSTOMER][NEUTRAL] On my end.
[CUSTOMER][NEUTRAL] OK, so.
[CUSTOMER][NEUTRAL] The policy number is 01677458M as in Mary L as in Larry 8.
[AGENT][NEUTRAL] OK, and then for security, can I get your first and last name and date of birth?
[CUSTOMER][NEUTRAL] So it's [PII]. My date of birth is [PII], but it's for my daughter.
[AGENT][NEUTRAL] OK, thank you so much, [PII], and then I need to verify the physical address and email address.
[CUSTOMER][NEUTRAL] [PII]. And I believe you might have [PII], otherwise, that's my husband's work email.
[AGENT][NEUTRAL] Yeah, no, we have the [PII]. OK, so it's in regards for [PII], correct?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Correct. Uh-huh.
[AGENT][NEUTRAL] OK, is it a claim for [PII]? Is that what we're needing to look at?
[CUSTOMER][NEUTRAL] Yeah, so, yep, it happened in June, um, she had a, um, sleep study and the big question, um, when I called up originally um was her sleep study was a.
[CUSTOMER][NEUTRAL] The evening and then into the day so it was, you know, [PII] and then [PII] I believe and so I know normally it's $1000 per individual per day.
[CUSTOMER][NEUTRAL] Um, however, um, when I called up about this test, even before we did it, they said that going into like, you know, staying over and going into
[CUSTOMER][NEUTRAL] The other day, there's a one time.
[CUSTOMER][NEUTRAL] Per or like a max amount for the year or something like that and it goes above 1000 a day and that's sort of the question.
[AGENT][NEUTRAL] OK, so I know that the outpatient benefit amount on the plan is per calendar day. I see that and it is $1000.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so the date of service.
[CUSTOMER][NEUTRAL] But this was an intake.
[AGENT][NEUTRAL] Oh, OK, it was June, what was the date? June.
[CUSTOMER][NEUTRAL] [PII]?
[AGENT][NEUTRAL] And do you have a claim number that was denied that I can look at?
[CUSTOMER][NEUTRAL] Hold on, let me find it see if I can find it.
[AGENT][NEUTRAL] Or a build amount.
[CUSTOMER][NEUTRAL] Because I don't have the
[CUSTOMER][NEUTRAL] Billed amount is $422.66.
[CUSTOMER][NEUTRAL] But I don't have an EOB here um.
[AGENT][NEUTRAL] OK, let me see what I can find for 6 1124 for 4 22 66.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so the original claim, it looks like was, excuse me, received, and then we requested the explanation of benefits from the primary insurance.
[CUSTOMER][NEUTRAL] Right, Blue Cross Blue Shield.
[AGENT][NEUTRAL] And then it looks
[AGENT][NEUTRAL] Yeah, and then it looks like there was another claim received and then that claim denied, stating that the maximum benefit payable for the state of service had been met.
[AGENT][NEUTRAL] There was a previous claim, it looks like for date of service [PII], that was a facility charge, and that
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Paid out the benefit max under the outpatient benefits for that date.
[CUSTOMER][NEUTRAL] Yeah, the only problem is she didn't leave.
[CUSTOMER][NEUTRAL] She, we came, we went in there on one day and we came out another day. So that would, that would be not an outpatient, right, like it's not, isn't that not to be same day.
[AGENT][NEUTRAL] Let, let me see.
[CUSTOMER][NEUTRAL] That's why when I, mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me pull the policy certificate and see exactly how they define.
[AGENT][NEUTRAL] Between inpatient and.
[CUSTOMER][NEUTRAL] Because I have an inpatient also number we have an inpatient and outpatient number.
[CUSTOMER][NEUTRAL] And that's like an amount for
[CUSTOMER][NEUTRAL] If I'm not mistaken, that's for an amount for the year.
[CUSTOMER][NEUTRAL] You know, different than the day rate.
[AGENT][NEUTRAL] OK, so on the policy, they define inpatient as confinement in the hospital for at least 18 hours continuous duration.
[CUSTOMER][NEUTRAL] Correct. And that's what it was. We were there for over 12 hours.
[CUSTOMER][NEUTRAL] In the hospital.
[CUSTOMER][NEUTRAL] In [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Now is that $1000 does that apply? You said it was paid to a facility, um, our bill is for the doctor.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right. So is that a different, is that a separate $1000 or what?
[CUSTOMER][NEUTRAL] No, it's supposed to be considered outpatient.
[AGENT][NEUTRAL] Yeah, I mean,
[CUSTOMER][NEUTRAL] Versus inpatient. So the question is, is because she, that doesn't matter if, if so like for example, when my daughter used to get infusions and the doctor would, you know, come in or there was a doctor who looked at the, her notes or any of that kind of stuff.
[CUSTOMER][NEUTRAL] That was all considered that same day, but she went in and she left the same day. She'd be in there for like 3 or 4 hours. We got there in the evening, stayed and slept overnight, and we left at like [PII]. We got in there around like [PII] and then left [PII] or so the night the next day.
[CUSTOMER][NEUTRAL] So that's exactly what that definition is.
[CUSTOMER][NEUTRAL] So that's why I pay the money to have this, so if she goes into the hospital for procedures.
[AGENT][NEUTRAL] OK, I may need to reach out to um the person that processed the claim itself so uh and see what we need to do on it.
[CUSTOMER][NEUTRAL] What is my benefit of, what is my benefit for in?
[CUSTOMER][NEUTRAL] What, what is my benefit for inpatient?
[AGENT][NEUTRAL] Uh, let's see.
[CUSTOMER][NEUTRAL] Once we're there for a straight 8 hours or however many hours you said.
[AGENT][NEUTRAL] Your inpatient benefit max is based off of a calendar year and the max on that is 6000.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And did we use any of it?
[AGENT][NEUTRAL] Let me see if anything's been used thus far this year.
[CUSTOMER][NEUTRAL] Well, not this year, [PII], but we, we haven't used, I know we didn't use it. That was the only one.
[CUSTOMER][NEUTRAL] So my point is that.
[CUSTOMER][NEUTRAL] We stayed the limit.
[CUSTOMER][NEUTRAL] And we're in a hospital.
[AGENT][NEUTRAL] Yeah, I don't see any usage for 24.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] And we had to meet how many straight solid hours?
[AGENT][NEUTRAL] 18 or more.
[CUSTOMER][NEUTRAL] Bye.
[CUSTOMER][NEUTRAL] So maybe
[CUSTOMER][NEUTRAL] Well, if I came in.
[CUSTOMER][NEUTRAL] Am I doing that right? Oh, it's, yeah, no, we met it because we came in in the evening and we left.
[CUSTOMER][NEUTRAL] The other evening within maybe.
[CUSTOMER][NEUTRAL] You know, not quite.
[CUSTOMER][NEUTRAL] Yeah, because 12 hours would have been [PII], so it was almost 24 hours.
[CUSTOMER][NEUTRAL] Right, if I, we came in around.
[CUSTOMER][NEUTRAL] Almost [PII] on.
[CUSTOMER][NEUTRAL] The [PII] and we left at almost [PII] on the [PII].
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So that's more than 18.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] All right. Let me see what we need to do um to turn, you know, to remedy it. If an appeal needs to be done or if it needs to be reexamined. Um, so I'm gonna double check on that. Let me place you on just a brief hold.
[CUSTOMER][NEUTRAL] Mhm. OK. You are on hold.
[AGENT][NEUTRAL] When was the claim process.
[AGENT][NEUTRAL] I
[AGENT][NEUTRAL] Uh
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] No.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] All right.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] I appreciate your patience and holding and I apologize for the long hold on that. Um, so I did reach out.
[CUSTOMER][NEUTRAL] No, hold on. I, I think this is the other lady. Hold on one second. I think she got disconnected.
[CUSTOMER][NEUTRAL] OK. She, she's, uh, what did you find out, [PII]?
[AGENT][NEUTRAL] Um, so I was advised if you think that the claim is processed incorrectly that the next step to do would be appealing the decision that was made, and you can appeal the decision in writing and I can give you um our address where you can send the appeal if you would like that.
[CUSTOMER][NEUTRAL] Um, OK, in the meantime, so I don't wanna make you, um, sit on, on hold, um.
[CUSTOMER][NEUTRAL] From you know billing and I'm sorry I forgot your first name, um, [PII], thank you [PII]. OK, so if you will just note that that's what I'm going to be doing because in my opinion exactly what she said is what we did, you know, we went in and it was 23 hours and all that good stuff. So uh if you need to go and you don't mind just at least like marking it in, how about how long does this process take once you know you receive it in writing.
[AGENT][NEUTRAL] Um, generally appeals take 30 days to render a decision.
[CUSTOMER][NEUTRAL] OK, so if you'll just kind of put in the notes there, I mean, obviously I have to mail it out, which I'll do, you know, in the next couple days here, um, and then, um, you know, hopefully within 30 days we'll have a decision and then will they be notified as well or am I just notified?
[AGENT][NEUTRAL] Um, so you'll just be notified since you're the one appealing it.
[CUSTOMER][NEUTRAL] OK, OK, and then, um, if you wanna you'll have to give it to us.
[CUSTOMER][NEUTRAL] What's that? Whatever you get from um American Public Life, send us a copy as well.
[CUSTOMER][NEUTRAL] OK how do I send you a copy? I can give you my email address and you can send it to me.
[CUSTOMER][NEUTRAL] OK, what's your email?
[CUSTOMER][NEUTRAL] It is [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK, and then if you wanna hop off and just put in the notes, I mean, you might wanna give me like it's probably gonna be closer to like, you know, I would say 40 you know days or whatever so that I can get this, this out and all that, um, and then, um, you know, if you need to go I totally understand and then I'll put the address [PII] from you.
[CUSTOMER][POSITIVE] Thank you [PII]. OK, um, and make sure you get everything, all the items that they require in the.
[CUSTOMER][NEUTRAL] The appeal.
[CUSTOMER][NEUTRAL] Yeah, I don't even know what that's gonna be. We will tell me. OK, thank you. All right, thank you, bye.
[CUSTOMER][NEUTRAL] OK, OK, [PII], where do I mail it to?
[AGENT][NEUTRAL] OK, so the appeal mailing address is you're going to address the envelope to [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And it's at [PII].
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] And that's in [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And the zip code is [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, and it basically just needs to be um something in writing stating why you're appealing the decision and then include you can include the claim number if you need that. I am happy to provide that as well.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, I don't think I have it because I don't think it's on whatever they've recently sent me.
[AGENT][POSITIVE] No problem. Uh, the claim number for [PII] was, uh, let me give you actually let me go.
[AGENT][NEUTRAL] I'm gonna give you both of them because there were 2 of them.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] And these claim numbers that were 2, is it because one is the 11th and one is the 12th, or?
[AGENT][NEUTRAL] No, so they both show date of service [PII]. The original was just denied because we needed your explanation of benefits from the primary.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. OK.
[CUSTOMER][NEUTRAL] Yeah, right.
[AGENT][NEUTRAL] So that claim number was 352.
[AGENT][NEUTRAL] 2274.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then the one ultimate.
[CUSTOMER][NEUTRAL] And that's the one you needed the EOB.
[AGENT][NEGATIVE] Uh-huh, yeah, and then the second one ultimately denied under the outpatient benefit max already being met for the day.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Yeah, but my point is that this is really impatient.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Because I guess what my thing is gonna say OK.
[AGENT][NEUTRAL] Right, exactly. And so I would just state on there that um it was actually an inpatient, not outpatient. And um because I've looked at what was submitted on the claim, and I see the dates as you stated, it shows, you know, um, [PII] and then [PII] and the different amounts and procedure codes. So I do see what you're talking about. Um.
[CUSTOMER][NEUTRAL] Right. One quick question, when they, the second claim, because could this be the issue? So I have two numbers, one is in and one is out, and the difference is like 1 digit off, and they always told me, oh you could give whatever. So one is 7 and one is 8 and so was this put underneath outpatient and it really should have been inpatient.
[AGENT][NEUTRAL] Um, and so that
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mm.
[AGENT][NEGATIVE] Yeah, no.
[AGENT][NEUTRAL] Hmm.
[AGENT][NEUTRAL] No, it's all the same policy. I mean, the policy has like a subset of benefits for inpatient and then outpatient, but it's all under the same policy number, so it shouldn't have mattered.
[CUSTOMER][NEUTRAL] Oh, OK, OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, because we have two different policy numbers, but they're exactly identical except for one digit, so I, you know, it gets too confusing to give everybody all of them, and I was pretty sure a long time ago when we had started with you guys that they were like, oh, it's pretty much the same thing so I just didn't know that potentially if that because we've never we've, I don't think we've ever used.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] Um, so far, knock on wood, I mean, like, it's not fun to stay in the hospital. Any, um, inpatient?
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] And so I, you know, I just, we've never, we, it, we've always had the $1000 a day, but um they said that because we stayed um over the night, and when I had called you guys originally, they said that that would go against my
[CUSTOMER][NEUTRAL] Amount for the year which I couldn't remember what it was um but like you said today or whatever it's 6600, right?
[AGENT][NEUTRAL] Right, right, right.
[AGENT][NEUTRAL] Um, I believe it was 6000. Let me go back.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Yeah, your inpatient for the calendar year is 6000.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So the the other claim number was 3,539,720.
[CUSTOMER][NEUTRAL] OK. And what's that number?
[CUSTOMER][NEUTRAL] OK, alright, I appreciate your help, um, but in my opinion, um, I'm hoping this appeal they'll realize that we never checked out, like, you know, I mean, we checked in and stayed overnight and was there, uh, the entire next day until she could be released.
[AGENT][POSITIVE] Yeah, not a problem.
[AGENT][NEUTRAL] Right, absolutely. Gotcha. OK, yeah, I would just submit that and I will notate our conversation, OK?
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you alright have a good day bye bye.
[AGENT][NEUTRAL] You too bye bye.