AccountId: 011433970860
ContactId: ab8363c4-2d3b-47c6-9dea-cbcfb0a7f7b2
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1631160 ms
Total Talk Time (AGENT): 502140 ms
Total Talk Time (CUSTOMER): 486606 ms
Interruptions: 2
Overall Sentiment: AGENT=0.8, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/14/ab8363c4-2d3b-47c6-9dea-cbcfb0a7f7b2_20250214T19:48_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. May I help you?
[CUSTOMER][NEUTRAL] Hi [PII], I was calling because I wanted to see uh if I had submitted my first claim. I'm, I'm very new to this, so I wanted to see if I submitted the claim correctly.
[AGENT][NEUTRAL] OK, and your name is?
[CUSTOMER][NEUTRAL] My name is [PII].
[AGENT][NEUTRAL] OK, and Mr. [PII], do you have your policy number?
[CUSTOMER][NEUTRAL] I do, give me one second here.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, my policy number is 0249.
[CUSTOMER][NEUTRAL] 64
[CUSTOMER][NEUTRAL] 62 ML 7.
[AGENT][NEUTRAL] OK, and verify your date of birth, mail address and email address for me, please.
[CUSTOMER][NEUTRAL] That's [PII].
[CUSTOMER][NEUTRAL] Uh, my mailing address is [PII], and then my email is [PII].
[AGENT][NEUTRAL] OK, thank you. And do you have a callback number in case the call drops?
[CUSTOMER][NEUTRAL] Yes, uh [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII]. Excuse me, I'm sorry.
[CUSTOMER][NEUTRAL] [PII] sorry I gave you the wrong callback number it's [PII]. My apologies.
[AGENT][NEUTRAL] OK, it's fine. We've been, we've been calling someone else. Let's see. OK.
[CUSTOMER][NEUTRAL] Brain parts.
[CUSTOMER][NEUTRAL] Yeah, right.
[AGENT][NEUTRAL] OK. And you wanted to make sure you filed your claim, uh, what we needed uh for your claim?
[AGENT][NEUTRAL] Uh, give me one.
[CUSTOMER][NEUTRAL] Yeah, I just wanted to make sure that I filed it correctly.
[AGENT][NEUTRAL] OK, give me one moment.
[AGENT][NEUTRAL] Because I do show a claim came in today and
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] OK. Um, looks like we have what we need. It has the diagnosis code and procedure code.
[AGENT][POSITIVE] So that's good, um.
[AGENT][NEUTRAL] And I will say this, um, do you have any other charges for that data service? Because it shows.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Because we always ask for the primary EOB which you submitted.
[AGENT][NEUTRAL] And I love this because it has diagnosis code needed, um, but there's no amount applied towards deductible, co-pay or co-insurance. So there will be nothing for us to pick up the secondary. Did you have any other charges for this data service like for the facility?
[CUSTOMER][NEUTRAL] Wait, I, I'm not understanding. What do you mean?
[AGENT][NEUTRAL] Because on your policy with our company, it picks up what primary insurance applies towards deductible, co-pay, or co-insurance and per the information you submitted on this ELB, it does not show any amounts for applied to those.
[AGENT][NEUTRAL] So, there would be nothing for us to pick up and pay a secondary. So I was trying to see if you had any charges like for the facility or anesthesia or any other charges for this day.
[CUSTOMER][NEUTRAL] Uh, I
[CUSTOMER][NEUTRAL] Let me see here, yeah, um, give me, give me one second. Uh, one second, hold on.
[AGENT][NEUTRAL] Yes sir.
[AGENT][POSITIVE] Who's your primary with because I, I'm really loving this EOB.
[CUSTOMER][NEUTRAL] Uh uh [PII].
[AGENT][POSITIVE] Oh wow.
[AGENT][POSITIVE] OK, because usually when the insured submit a claim, um, they might submit an EOB or bill, but it doesn't have the diagnosis codes and it put a delay, but theirs is awesome because it has the diagnosis and procedure codes on it.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][POSITIVE] Uh, yeah, it was pretty neat when I opened it up, um.
[CUSTOMER][NEUTRAL] Let me see if this is the document that I had sent over to you.
[CUSTOMER][NEUTRAL] That I had submitted I'm sorry, and.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] One second here.
[CUSTOMER][NEGATIVE] Yeah, for some reason it doesn't show.
[CUSTOMER][NEUTRAL] Because it says amount bill.
[CUSTOMER][NEUTRAL] Is this
[CUSTOMER][NEUTRAL] Hold on, bear with me a moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 72.
[CUSTOMER][NEUTRAL] One second here because.
[CUSTOMER][NEUTRAL] That's uh
[CUSTOMER][NEUTRAL] That's strange to me.
[AGENT][NEUTRAL] Yeah, because based on SCOB, it looks like your primary paid in full.
[CUSTOMER][NEUTRAL] Because
[CUSTOMER][NEUTRAL] So how would I, how would I be able to identify that?
[CUSTOMER][NEUTRAL] Like if it says 0 co-pay, then.
[AGENT][NEUTRAL] No, um, well, if you look at the EOB, it'll show co-pay, co-insurance and deductible. If that 0, that's, there will be nothing for us to pick up and pay as your secondary, and it shows on here patient responsibility is 0.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] So it shows it looks like the primary paid it in full.
[CUSTOMER][NEUTRAL] Hm
[AGENT][NEUTRAL] And the reason why I asked if you had any charges for like the facility or anesthesia or diagnostic, um, you can submit those just so you can have a benefit because this one, we can't process claims on the phone, but more likely it will be processed as primary paid in full.
[CUSTOMER][NEUTRAL] OK, now I understand.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Yes yeah what I'm trying to see here is.
[CUSTOMER][NEUTRAL] So that one says 34 I'm trying to see, give me one sec.
[CUSTOMER][NEGATIVE] That's, that's impossible. I'm getting charged for the same thing though.
[AGENT][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] And it says my plan paid for.
[AGENT][NEUTRAL] Cause what I'm looking at, it looks like for a surgery.
[AGENT][NEUTRAL] Looks like surgeon's charge, maybe?
[CUSTOMER][NEUTRAL] We see
[CUSTOMER][NEUTRAL] Yeah, the one that I'm looking at.
[CUSTOMER][POSITIVE] It is funny work um.
[CUSTOMER][NEUTRAL] Yes, I'm looking at the same one that we're looking that I have filed and I'm looking at it on the Amet portal.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Which is the partial removal of my thyroid.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEGATIVE] But the thing is, is that was, that was a surgery that was billed to me and, and I'm still getting that. I'm, I, I have to pay an amount, but it's not, it's showing as if I don't have to pay anything.
[AGENT][NEUTRAL] Yeah, cause it's showing, like I said, it shows patient responsibility 0 and the amount they allowed is the amount that your major medical paid.
[CUSTOMER][NEUTRAL] yeah, but so, so look, it says um.
[CUSTOMER][NEUTRAL] So the amount billed is 2, is almost $3000 on that one, but then it says my plan paid $1300 so where's the difference?
[CUSTOMER][POSITIVE] Good
[CUSTOMER][NEUTRAL] That's where I'm a little bit confused.
[AGENT][NEUTRAL] Yeah, that's something you may have to um verify with your primary. It could be because that uh physician is in a network or if you have um in an out of network, they there's like a certain amount that they would charge or a certain amount that is approved.
[CUSTOMER][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Like you see on there it says a loud amount.
[AGENT][NEUTRAL] And then it shows uh the plan paid that amount, um, I'm assuming it could be because that maybe that physician was in their network.
[CUSTOMER][NEUTRAL] Right?
[CUSTOMER][NEUTRAL] Right, like, OK, so I just saw here.
[CUSTOMER][NEGATIVE] What I'm not understanding.
[CUSTOMER][NEUTRAL] So there's another claim.
[CUSTOMER][NEUTRAL] See here.
[CUSTOMER][NEUTRAL] Alright
[CUSTOMER][NEUTRAL] Look, I'm gonna, I'm gonna, I'm gonna submit another claim now.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, and it seems like it's the same one, but this time around it shows that there's a co-pay amount.
[AGENT][POSITIVE] Oh, OK, good.
[CUSTOMER][POSITIVE] Maybe you can maybe help help provide me with some guidance on this.
[CUSTOMER][NEUTRAL] One
[CUSTOMER][NEUTRAL] I'm gonna go ahead and do that now.
[CUSTOMER][NEUTRAL] You wanna go to the appointment.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I the
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I'm submitting another one now.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] You can help walk me through the difference slowly.
[AGENT][NEUTRAL] And you're submitted through the online service center?
[CUSTOMER][NEUTRAL] Yeah, let me see here if it's loading up still.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Let me just, I gotta maybe exit out and do it again because it's giving me like some form of an error.
[AGENT][NEUTRAL] Oh no, OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mm yeah.
[CUSTOMER][NEUTRAL] Now it's loading again.
[CUSTOMER][POSITIVE] Alright, alright, so I just submitted it so successful.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, do you have that confirmation number so I can look for it?
[CUSTOMER][NEUTRAL] Can you tell me if you.
[CUSTOMER][NEUTRAL] Uh,
[AGENT][NEUTRAL] Like OC, OK.
[CUSTOMER][NEUTRAL] I don't have a company.
[CUSTOMER][NEUTRAL] Oh yeah, yeah.
[CUSTOMER][NEUTRAL] I have uh OSC 934.
[CUSTOMER][NEUTRAL] 69
[AGENT][POSITIVE] OK, thank you. Give me one moment, I'm gonna look for it real quick.
[AGENT][NEUTRAL] Oh wow, that came in, well, no, this is, is it? No.
[AGENT][NEUTRAL] say it came in pretty fast, but it's another one. Give me, give me one moment.
[AGENT][NEUTRAL] We're just gonna give it a moment. Sometimes it takes a while for me, um, for us to be able to see it once it goes through.
[CUSTOMER][POSITIVE] No worries.
[CUSTOMER][POSITIVE] No worries.
[CUSTOMER][NEUTRAL] So essentially, the claims that I would have to look at or look for from my primary are the ones that have a patient responsibility amount.
[AGENT][NEUTRAL] Or was that, yeah, and if it shows deductible amounts applied towards deductible co-pay or co-insurance.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] Oh, this is.
[CUSTOMER][NEUTRAL] So like, like if it says plan paid and then it's a certain amount and then patient responsibility it's another certain amount those are the ones that I wanna look for.
[AGENT][NEUTRAL] Uh, yes, and then I would say like the one that you submitted, kind of look and see if they show any amounts applied towards deductible, co-pay, co-insurance, because those are the amounts we're looking for specifically for secondary.
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh
[AGENT][NEGATIVE] Oh, this computer is slow.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] It seems to me like uh.
[CUSTOMER][NEUTRAL] But this is looking like is um.
[CUSTOMER][NEUTRAL] Some of these are broken into like separate parts, but, but are all within the same.
[CUSTOMER][NEUTRAL] Claim on my primary, so it looks like so I gotta look for the original one that has.
[AGENT][NEUTRAL] Well,
[AGENT][NEUTRAL] Well, usually, like if you have any kind of um
[AGENT][POSITIVE] Services performed, especially outpatient or in hospital. You're gonna have something from the facility, something from the, like your case the surgeon, anesthesiologist, sometimes diagnostic or lab. It's like everybody bills you except for one bill, which would be awesome.
[CUSTOMER][NEUTRAL] It's
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right, right.
[CUSTOMER][NEUTRAL] That's what, that's what I'm noticing here, so, so that's why maybe the one that I sent you was, wasn't necessarily the one that I had to pay for. It was probably the all encompassing one.
[CUSTOMER][NEUTRAL] Uh, that gave a breakdown.
[AGENT][NEUTRAL] It could be or the facility or, yeah, um.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Well, I'm so sorry, it's coming through pretty slowly and it can take a while for us to see. Would you like for me to, um, I'll keep monitoring it, and do you want me to give you a call back?
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Yeah, that'd be great, please, if you can. Uh, I would, I, I do have a question. So a lot of these, um, unfortunately, I was, uh, I was diagnosed with, with, uh, cancer, uh, earlier this year, and I felt like, like, no, it's all right. Thank you. And uh I'm good now, thankfully, but, but I guess the reason why I mentioned it is because
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I'm sorry. Mhm.
[CUSTOMER][NEUTRAL] Uh, I had waited to do all this stuff until I had the gap insurance, right? Um, now, silly me, I didn't do any research and I did, I was under the impression that as long as I showed my primary, the gap would be in effect. I came to learn after already paying for some of my bills.
[CUSTOMER][NEUTRAL] That if I show the, I had to show the gap insurance afterwards to be able to get some of, you know, some of the, some, some more of the cost eating out already, um, would it, would it affect me in a negative way, being that I've already paid for some of these bills or it doesn't necessarily matter?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Oh, it wouldn't necessarily matter. You don't matter as far as, um, these are, well, no, it wouldn't matter. Um, you can still submit to be reimbursed benefits that are payable.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][POSITIVE] Got it. OK, so, so I'm still in good shape as far as submitting the claims and doing that process.
[AGENT][NEUTRAL] Yes, like, um,
[CUSTOMER][NEUTRAL] OK
[AGENT][POSITIVE] Because anytime you file a claim, or anytime I guess you say you have service, just give me your uh when you give me your primary, give me your secondary information, but if you have to file, you can, and then any payable benefit will go to you instead of the provider. So you and there's not a time limit to submit, so you're good.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I understand.
[AGENT][NEUTRAL] And your callback [PII]?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Yes, perfect.
[AGENT][NEUTRAL] OK, OK, I'll keep it, oh, well, it popped up, but for some reason I didn't.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Oh look at that.
[AGENT][NEUTRAL] As soon as I say I'll call you back, it popped up. Give me one moment.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Let's see.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Well, OK then.
[AGENT][NEUTRAL] That's what I'm gonna start doing and start saying, let me call you back and see if it pops all up.
[AGENT][NEUTRAL] 67.
[CUSTOMER][POSITIVE] No worries. I was like to be.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Let's see.
[AGENT][POSITIVE] Oh, this is good. Yes.
[AGENT][POSITIVE] It shows the co-pay amount. Yes, so you're good.
[AGENT][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] So what would, what would be the next steps now?
[AGENT][NEUTRAL] Uh, the next step is, um, we received it today, usually from the time a claim is received, it can take 7 to 10 business days to process. Um, did you set up on the online service center to where you can receive a text message on when it's processed and when it's received?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright
[CUSTOMER][NEUTRAL] I didn't, but would you be able to help me do that?
[AGENT][POSITIVE] Uh, yes, I can give it a try.
[CUSTOMER][NEUTRAL] I, you know what?
[CUSTOMER][NEUTRAL] Yeah, no, no, I didn't. I thought I received the text, uh, after sending this. Alright, I'm here in front of it.
[CUSTOMER][NEUTRAL] Sorry.
[AGENT][NEUTRAL] And all this was performed outpatient?
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Or where you can find.
[CUSTOMER][NEUTRAL] In in uh yeah, I'm sorry, uh, an observation center.
[CUSTOMER][NEUTRAL] But I stayed, I stayed one night.
[AGENT][NEUTRAL] OK, give me one moment.
[CUSTOMER][NEUTRAL] I think, I think the threshold, I remember talking to another person, uh, uh, with you guys, they told me uh that it had to be a minimum of 18 hours.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm. 18 hours or more.
[CUSTOMER][NEUTRAL] To be able to to
[CUSTOMER][NEUTRAL] Right, to be able to get a certain uh jump of coverage, um, if I need to get the documentation, I, I could to prove that I was there for more than 18 hours. I think I had gotten discharged in the, I wanna say the 20th hour, um, so if you guys need that I could provide that.
[AGENT][NEUTRAL] Oh, yes.
[AGENT][NEUTRAL] I would say to submit that, please, because just looking at the information we have.
[AGENT][NEUTRAL] Um, it's this one looks like it was for facility. It doesn't show that, um, confinement. It doesn't show admitted discharge. So if you have information from the hospital where it shows when you were admitted and discharged, I would say to definitely submit that so we can, um, so it can be processed as inpatient if you were there 18 hours or more, it's because more like it could have been processed as outpatient.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you
[CUSTOMER][NEUTRAL] Got it. How would I add it to that claim?
[AGENT][NEUTRAL] Uh, if you won't be able to add it to the claim, you can just do it as a new claim, but when the examiners process it, they're gonna add it all together. They're gonna put it all together when they process.
[CUSTOMER][NEUTRAL] OK, so they'll be able to know what's what.
[AGENT][NEUTRAL] Oh, yes, sir.
[CUSTOMER][NEUTRAL] OK, cool. uh, do I have to do anything with the, with the, with the initial claim that I did, the one that that didn't have like any co-pay or anything there?
[AGENT][POSITIVE] No, um, like I said, more likely when they process it, they'll just process it primary paid in full and then more likely pay on the other one. And like I said, it's really good that they had diagnosis codes on your EOBs, that is perfect.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] Alright, yeah, hopefully, hopefully it helps out hopefully I get some help that'd be that'd be great.
[AGENT][NEUTRAL] Oh, absolutely. But yeah, if you have the information from the hospital, um, go ahead and submit it, um, and you can just do it as a new claim, that way we'll know that it was inpatient and not outpatient.
[CUSTOMER][NEUTRAL] Alright, is it preferred that it's an actual like PDF file or or or pictures fine because I, I would like I have the discharge papers with me but I have them obviously hard copy.
[AGENT][NEUTRAL] Yeah, I would say you, you can submit pictures, uh, people do it all the time, just make sure that it's clear and legible.
[CUSTOMER][POSITIVE] OK, perfect.
[CUSTOMER][NEUTRAL] Alright, alright, if I have any other questions I'll definitely, uh, I'll reach out. I'll be uploading some more claims also, so, uh, it's good to know that I, they gotta look like that one that I that I just submitted right now, OK.
[AGENT][NEUTRAL] Yes, sir.
[AGENT][NEUTRAL] OK, well,
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, and is there anything else I can assist you with today, Mr. [PII]?
[CUSTOMER][NEUTRAL] All right bye.
[CUSTOMER][POSITIVE] No, you've been a great help. I appreciate it thank you.
[AGENT][POSITIVE] Oh, you're welcome. Uh, thanks for calling APL. You have a great day and weekend.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Alright, like.
[AGENT][NEUTRAL] Mm bye.