AccountId: 011433970860
ContactId: aea552fa-0417-47b5-be75-0ff02dc00a68
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 659640 ms
Total Talk Time (AGENT): 295902 ms
Total Talk Time (CUSTOMER): 358745 ms
Interruptions: 3
Overall Sentiment: AGENT=0.6, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/31/aea552fa-0417-47b5-be75-0ff02dc00a68_20250331T15:14_UTC.wav
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[AGENT][NEUTRAL] Good morning. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, [PII]. My name is [PII]. I am a member of the GAP insurance with you guys. And I got um a letter from um the place where I had my colonoscopy done.
[CUSTOMER][NEUTRAL] And they asked me to um
[CUSTOMER][NEUTRAL] Uh, get in touch with you guys because they spoke with you and I have to update my COB file.
[CUSTOMER][NEUTRAL] So that, you know, the coordination of benefits so that you guys can process the insurance uh you know, whatever the claim is. So,
[AGENT][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] I am not sure if I need to do anything with you guys to make sure that everything is, uh, it's under control so that whatever needs to be paid gets paid or processed. So, should I give you my numbers?
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Um, yeah, go ahead with the, yeah, go ahead with the callback number and then the policy number so I can pull your information and see what's happening, OK?
[CUSTOMER][NEUTRAL] My information?
[CUSTOMER][NEUTRAL] Uh, the callback number is [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, and what's the policy number?
[CUSTOMER][NEUTRAL] Um, I have a group number that is 16291.
[AGENT][NEUTRAL] What about the um
[CUSTOMER][NEUTRAL] And I don't know if what you need is the plan, the plan is the Metlink select group Med soup.
[AGENT][NEUTRAL] Certificate?
[AGENT][NEUTRAL] In the bottom.
[CUSTOMER][NEUTRAL] There's in-hospital and out uh there's two numbers. The, the in-hospital benefit certificate number is, OK, 1,306,740 M as in mother, L as in Lima 7. That's for in-hospital benefits.
[AGENT][NEUTRAL] Give me one of the two.
[CUSTOMER][NEUTRAL] And the outpatient is the same number but ML and 8.
[AGENT][NEUTRAL] OK. And um Miss [PII], may I have your date of birth, mailing address and email address for verification for security.
[CUSTOMER][NEUTRAL] Sure. It's [PII], [PII]. D [PII]. And I'm missing one address.
[AGENT][NEUTRAL] Address.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] All right. OK. So we're always gonna be your secondary because we don't carry any primary insurance. Uh-huh. So, um, yeah, the COB is usually handled by your major medical.
[CUSTOMER][POSITIVE] Correct.
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] So if somebody needs to um fix or um do any changes to their COB which is the coordination of benefits, it has to go through the major medical, the major medical needs to know who's your secondary.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Because
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Because it's for what?
[CUSTOMER][NEUTRAL] For some reason, they, they, what they wrote is American Public Life has advised us that the above reference claim is pending because your coordination of benefits file needs to be updated.
[AGENT][NEUTRAL] Oh, what is the date of service? Mhm.
[CUSTOMER][NEUTRAL] So I mean the thing is that I don't have.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] The, the date of service is uh
[CUSTOMER][NEUTRAL] Let me, it's [PII].
[CUSTOMER][NEUTRAL] And actually I do have uh a paperwork from you guys that I got with a reference and policy and all these different things.
[CUSTOMER][NEGATIVE] Where it says, uh, that, you know, of course, there, you guys are paying 0 and it says insured, primary insurance provided full benefits, there are no benefits payable. When I go to the the, the explanation of, of the benefits, it says that um my deductible is 63874.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] So that is my cost. So that is what should be covered by you guys, right?
[AGENT][NEUTRAL] OK, which claim are you looking at?
[CUSTOMER][NEUTRAL] Because you're, you're, it's not a secondary, but uh I I the the actual, the actual um
[CUSTOMER][NEUTRAL] The actual, you know, visit of the malignant neoplasm of colon, that it's the, the [PII]. This is the actual, this is the actual, the actual insurance claim from Florida Blue, that it's my main insurance.
[AGENT][NEUTRAL] The the facility charge?
[AGENT][NEUTRAL] OK, yeah, I understand that, but like, uh, are you looking at the 5500 charge or are you looking at the 1,195 charge or which, which charge are you looking at? Because I have several, for the same date, I have several charges.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] He
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, I have the, the one that I have in front of me right now within my claims. It's uh the one that it's for cost, the total amount for the provider is 10,300.
[AGENT][NEUTRAL] Uh.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK, so you're probably talking about the facility. OK. All right. Mhm.
[CUSTOMER][NEUTRAL] That, that's the total.
[CUSTOMER][NEUTRAL] Then, uh, uh, yes, and then it says the amount my plan paid is 168577.
[CUSTOMER][NEUTRAL] So my total savings is 1618, blah blah blah, but it says that I have my deductible of 638. 74.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So that is my cost.
[AGENT][NEUTRAL] OK, bear with me just a second. I have to look at.
[CUSTOMER][NEUTRAL] And then if you
[CUSTOMER][NEUTRAL] And actually, there, there's a summary where there is the 5500 that appears there too.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK. Yeah, I.
[CUSTOMER][NEUTRAL] I don't know why there's 2 amounts.
[AGENT][NEUTRAL] OK, I just need to be looking at the information that was sent with it to know why we decided that there was nothing applied, OK? Um, let's see, so the the amount was 10,300.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] 16574.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] There's any cos here.
[AGENT][NEUTRAL] OK, you see that's why. OK, so it's missing a document. Let me see what document is missing.
[CUSTOMER][POSITIVE] Yes, thank you.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Yeah, it will be the only reason we will deny something indicating that um.
[AGENT][NEUTRAL] It's just not exactly what it is or something like that because it's missing information. OK, so basically the reason for that is um for that explanation of benefits or that process of that claim is because the one we receive um the claim form, not the explanation of benefits, the claim form, was only for the 5500, so they kind of like.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Slit it, I guess, um, so they only send us the charge for 5500. Now the one that has that um deductible amount apply is not the 5500, it's the other portion of it, and they did not send that charge and the information on that portion. So um what we need is for the provider of service to send us the complete claim that matches the EOB that matches the explanation of benefits.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] OK, yeah, because I mean this is, I mean, personally I don't understand why the cost care for my provider is the 10,300 and then on the bottom on the summary of costs, ambulatory surgical care on the general classification, it says total bill cost 5500.
[CUSTOMER][NEUTRAL] Uh, the Florida Blue discount 0 amount my plan paid $1600 limits and exclusions is 0. So my total responsibility is 0, but on top, it says that my cost is 638.
[CUSTOMER][NEGATIVE] And there's no, no exclusions, no limits. My co-insurance is 0. My deductible is 638. 74. My co-payment or co-pay is 0. So, and the total service is 16, you know, 16 and 8500 6 1,68577 doesn't matter. So it I'm, I, I am absolutely confused by how this is read. This is supposed to be red.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so it looks they usually charge per service render. So, um, in this case, there were two services that were rendered that date of service for that visit, um, and they charge one of them, but they did not charge the other one, which, um, the one that we're looking at again is the one for 5500, which is the procedure code 45,380.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Um, and then the 43239, that procedure code, I don't know if you see that, but that procedure code is not listed on the claim, and that's the one that has the $638.74 allowable, which is applied towards the deductible.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] No
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So to resolve this one, all we need to have is the provider to send us the full claim with both procedures.
[CUSTOMER][NEUTRAL] OK, so
[CUSTOMER][NEUTRAL] OK. OK. I'm gonna call them right now and ask them to then resend whatever, everything, the both things, not one.
[AGENT][NEGATIVE] Yeah, to resend, um, they need to resend a fully.
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] Itemized bill with both procedures, not just one.
[CUSTOMER][NEUTRAL] Oh, so let me.
[CUSTOMER][NEUTRAL] fully itemized.
[CUSTOMER][NEUTRAL] Procedure.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah. OK, and it has to have the two procedures. The procedure 35,380.
[CUSTOMER][NEUTRAL] With both bills.
[AGENT][NEUTRAL] And the procedure 43239, which is the one we're missing. 43239 is the missing procedure.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I'm sorry, could you repeat the, the number? It's 431.
[AGENT][NEUTRAL] OK, the first one, which is the one we have is 45,380, 45,380.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] 380
[AGENT][NEUTRAL] OK, the one we're missing is 43239. Again, that's 43239.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] 43239. OK. OK. OK, let me call them right now and let's see if we can get this little show on the road.
[AGENT][NEUTRAL] All right. OK.
[CUSTOMER][POSITIVE] Thank you very much. I do appreciate your help on this one and hopefully we'll get, I'll get to the end of it and, you know, we can just solve it.
[AGENT][NEUTRAL] Uh
[AGENT][POSITIVE] You're welcome.
[AGENT][POSITIVE] Sure, no problem. Is there anything else I'm gonna help you with today? Any other questions or concerns, Monument?
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][POSITIVE] No, this is perfect. Thank you very much. I do appreciate your time. Thank you so very much.
[AGENT][POSITIVE] You're welcome. No problem. Thank you for calling APL. You have a good day. You're welcome. You too. Bye-bye. Thank you. Bye-bye.
[CUSTOMER][POSITIVE] Take care.
[CUSTOMER][POSITIVE] You too. Thank you. Bye bye.