AccountId: 011433970860
ContactId: aacac043-6547-4601-ba7f-4bb41419a771
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 516210 ms
Total Talk Time (AGENT): 283416 ms
Total Talk Time (CUSTOMER): 250470 ms
Interruptions: 7
Overall Sentiment: AGENT=1.4, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/19/aacac043-6547-4601-ba7f-4bb41419a771_20250519T16:46_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling ATL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] Hi, [PII]. My name is [PII]. I am, um, I am, um, uh, a patient or member of, of APL. And I was wondering um uh
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] I got a bill from my, from a colonoscopy I had done, uh, it was from the actual place. Uh my insurance paid a portion of it, and there's a portion that is a deductible. Uh, when, when the, the, the, the, the facility sent that stuff to APL to get covered, they said that I have to pay it.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So I was wondering what was the deal, if you can help me.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Sure, absolutely I can make sure of course that we did receive that claim uh and then get clarification on that and see what's going on, um, before we go any further, can I get a good call back number from you in case we're disconnected please?
[CUSTOMER][NEUTRAL] So where should we start?
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Yes, absolutely. [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, thank you and then do you have your policy number?
[CUSTOMER][NEUTRAL] Yes, I have, uh, would it be the group number?
[AGENT][NEUTRAL] No, are you looking at your card right now?
[CUSTOMER][NEUTRAL] Or the, the plant.
[CUSTOMER][NEUTRAL] Yes, I am.
[AGENT][NEUTRAL] Um, do you see anything on there that says in hospital or outpatient certification number?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yes. I have an, an inhospital and outpatient.
[AGENT][NEUTRAL] OK, either one of those, please.
[AGENT][NEUTRAL] Either one of those please.
[CUSTOMER][NEUTRAL] OK, it's 13.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK. 1,306,740 ML 7 for in hospital and and on 8, it is an outpatient dentist.
[AGENT][NEUTRAL] Got it. OK, thank you for that [PII]. Uh, just gonna verify some information really quick. Uh, can I get your date of birth please?
[CUSTOMER][POSITIVE] Yes, absolutely.
[CUSTOMER][NEUTRAL] Of course, [PII].
[AGENT][NEUTRAL] Thank you and then can I get your mailing address?
[CUSTOMER][NEUTRAL] It's [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 Hotmail account.
[CUSTOMER][NEUTRAL] Oh yeah, it's [PII].
[AGENT][NEUTRAL] OK, thank you for verifying all of that. OK, now was this claim for you or for somebody else under your policy?
[CUSTOMER][NEUTRAL] No, for me.
[AGENT][NEUTRAL] It was OK, give me just a moment. Do you happen to know the date of service?
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] Yes, it was, uh, [PII]. I would say [PII], that would be live so far away.
[AGENT][POSITIVE] Perfect. OK.
[AGENT][POSITIVE] All right, thank you for that one moment let me try to find that.
[CUSTOMER][NEUTRAL] It was for a colonoscopy.
[AGENT][NEUTRAL] Got it. OK.
[AGENT][NEUTRAL] Looks like we have a few claims from that data service so let me take a look.
[CUSTOMER][NEUTRAL] This belongs on, on one of the bills that is 10, 10,0001.
[CUSTOMER][NEUTRAL] Because I was just now with the insurance on the, on the phone, so they're the ones that told me where it was.
[AGENT][NEUTRAL] Sure, OK, so I don't have any for 10,000. I do have one that is from, uh, let's see.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Ambulatory anesthesia associates, um, and that was for $680 and looks like we did pay that benefit. Let me check these other two.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] No, not that one.
[AGENT][NEUTRAL] OK, I have another one for $1,195.44 and another for $5500.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Let me check both of those out, give me just a moment.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah, I mean, the things that it seems that the amounts that you guys get are different from the amounts that we get on the bill, so.
[AGENT][NEUTRAL] So the amounts that we get should be um what is left over after your primary medical pays so that's what this whole policy helps with um co-pay deductible and co-insurance after your primary pays. Now I will say I did find one [PII], this one that was for $1195.44. We are missing that copy of the primary EOB and that's why this one denied is we're just missing some information and this was from.
[CUSTOMER][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] MPV New Jersey MD Services.
[CUSTOMER][NEUTRAL] So, uh, I have no idea because I mean for me the bill comes under Pleasant Dale Ambulatory care and it says, uh, colonoscopy, flexible, proximal to SP 5 5500, and then it says insurance write-off.
[AGENT][POSITIVE] Oh, I do have one. Yes.
[AGENT][NEUTRAL] Go ahead, I'm sorry.
[CUSTOMER][NEUTRAL] OK, this one is the 5500, yeah.
[AGENT][NEUTRAL] OK, so this one I have for 5500. I did find that one that you're talking about and according to the information we have, there was no benefits payable as your primary insurance provided full benefits, so there was nothing additional for us to pay.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Actually,
[CUSTOMER][NEUTRAL] I actually I have uh in in front of me, I mean the thing is that, you know, as you know, what you have is different from what I have and whether the insurance or not. Everything is different, uh, and actually on the actual bill that I got from them, it said, um, the, the write off was a 3995 and the insurance payment was 1102, and there was a correction to the write off and then a payment due of 638. 74 cents are due.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I spoke to the insurance, uh, they, yeah, the insurance told me that, uh, that, that, yeah, that they cover that stuff and that the 638 was my deductible. But I was like, where can I find this? So they were like, go to your uh uh explanation of benefits. So I went to, to the actual thing. I went to explanation of benefits and the 638 appear as a deductible.
[AGENT][POSITIVE] Oh my goodness. Uh-huh.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] I see. And
[CUSTOMER][NEUTRAL] My deductible before the visit you spend 0 work and say $638 is 24 cents is the exact same amount. Uh, so, so if, so if this, if, if this is a deductible, shouldn't be covered by the APL?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right, right.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, absolutely, um, and that's what I'm, I think, so let me ask you this, um, did you pay that amount [PII] or is that still just a bill that you received?
[CUSTOMER][NEUTRAL] So I, I don't know, I don't know where it disconnected.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] I just, I just got the bill on Friday.
[AGENT][NEUTRAL] Awesome, OK, OK, so here's what I would recommend, um, and of course I'll provide you all of the possible solutions just so you know, but I would say first course of action is going to be contacting that facility telling them that you did speak with us.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] And that it looks like we're missing some information. I would strongly encourage them to give us a call so we can go over exactly what was sent if there's any confusion, you know, obviously you wouldn't have to play middleman and that um and we can go to them and tell them exactly what it is that we need so they can send that to us and get that taken care of, um, and they can call us we talk to providers all the time so the same number that you called, they are more than welcome to give us a call so we can try to get this cleared up for you, um.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK perfect.
[AGENT][MIXED] Because as it stands again I have 3 claims for that data service we paid 1 for 680, the others it's stating either there was no benefits payable or that we're missing the primary EOB. So I do think they need to give us a call now if you know all providers are very different, um, so it's can be hit and miss with how they are um I would hope most are very nice and say OK yeah we'll give them a call if not if they give you any kind of push back if they say they don't mess with that.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It is possible for you to file these claims yourself it's just a bit more roundabout, so I would recommend trying to contact them first, um, seeing if they're able to reach out to us regarding all of this. If not, give us a call back and then we can walk you through how you can get the claims filed yourself.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] OK, perfect. I'm gonna call them right now because I, they, they were the first ones that I called and they told me that you guys said that it was my responsibility to pay because the insurance hadn't covered.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEGATIVE] But the insurance had covered. I mean, that's a lie.
[AGENT][NEGATIVE] I'm not seeing anything for again.
[AGENT][NEUTRAL] Go ahead, I'm sorry.
[CUSTOMER][NEUTRAL] So that's weird. Yeah, so it's like, it's like weird. It's like there is like, like.
[AGENT][NEUTRAL] There might be some confusion and that's right exactly might be some sort of miscommunication there because for this date of service for [PII] I've just got these three claims and that's what they're saying so I would definitely um have them call us so we can clear this up.
[CUSTOMER][NEGATIVE] A piece missing, you know, that's what you're saying.
[CUSTOMER][NEUTRAL] Mhm mhm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] OK, perfect. I'm gonna call them right now. If not, I'll, I'll call you so that I can, or I'll call you guys to see if you guys can walk me through the claims.
[AGENT][POSITIVE] Sounds good. Absolutely.
[AGENT][POSITIVE] Absolutely, yes, ma'am.
[CUSTOMER][POSITIVE] Well, that's so much, thank you so much, [PII]. I do appreciate so much for your time. Thank you so much.
[AGENT][POSITIVE] You are very welcome. You are very welcome have a great rest of your day.
[CUSTOMER][POSITIVE] You too. Thank you. Bye-bye, [PII].
[AGENT][POSITIVE] Thanks bye bye.