AccountId: 011433970860
ContactId: aef9e0f4-03fa-489e-b73c-6148a3ce39e7
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 948159 ms
Total Talk Time (AGENT): 556300 ms
Total Talk Time (CUSTOMER): 376272 ms
Interruptions: 15
Overall Sentiment: AGENT=0.4, CUSTOMER=-0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/19/aef9e0f4-03fa-489e-b73c-6148a3ce39e7_20250519T17:57_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, uh, [PII], my name is [PII], and I'm calling because y'all keep denying claims.
[CUSTOMER][NEUTRAL] And I, I need to find out why.
[AGENT][NEUTRAL] Sure I could take a look at those uh denials and get some clarification for you. I'm so sorry, what did you say your name was?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK and then can I get a good call back number from you in case we're disconnected please?
[CUSTOMER][NEUTRAL] Sure, it's [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you, do you have your policy number?
[CUSTOMER][NEUTRAL] Uh, it's 02135063.
[AGENT][NEUTRAL] OK thank you one moment.
[AGENT][NEUTRAL] Alright, and then just gonna verify some information really quick, uh, Don, can I get your date of birth please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you and can I get your mailing address?
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And [PII].
[AGENT][POSITIVE] Perfect, last thing I need is the email address we've got on file for you.
[CUSTOMER][NEUTRAL] Um, I think you have [PII].
[AGENT][NEUTRAL] Yes ma'am, that's it. OK, thank you for verifying all of that. OK, so I will say right off the bat I do see two claims that looks like they just completed processing uh today so let me take a look at those, give me just a moment.
[CUSTOMER][NEUTRAL] It's like everything since January has been denied saying that um
[CUSTOMER][NEUTRAL] It's pending due to benefit renewal information from your employer group.
[AGENT][NEUTRAL] Yes, I do see that and that's what this looks like I'm sorry, go ahead.
[CUSTOMER][NEUTRAL] Um, and
[CUSTOMER][NEUTRAL] We've called multiple, what's called multiple times. And I keep being told, yes, there is coverage, submit the claims and
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] You know I had my employer call I've had um.
[CUSTOMER][NEUTRAL] Our insurance agent call.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] And I don't understand why because
[CUSTOMER][NEUTRAL] You know, up until when, when did I have the.
[CUSTOMER][NEUTRAL] In [PII], I think it was. I had the, no, wait, that was chemo um early May, um, I think [PII], it might have been.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] Um, we called and everything was confirmed and y'all were supposed to call the hospital and confirm that yes, there is coverage but yet even still after that, I still am getting notices saying that.
[CUSTOMER][NEUTRAL] Yeah, or confirming um coverage.
[CUSTOMER][NEUTRAL] That it's uh pending due to benefit renewal information.
[AGENT][NEUTRAL] Mhm, yes, OK, so I can provide some, sure.
[CUSTOMER][NEGATIVE] So I don't understand. I, I need to figure out the problems.
[AGENT][NEUTRAL] Absolutely. So, and it does look like you probably called it the best time, um, because again I do see these most recent claims and that's what they look like that they were those claims from before that had, um, simply been reprocessed. So this one for example I see is from uh Oshner clinic, I think that's how you say it, Osher uh clinic.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah. Mhm.
[AGENT][NEUTRAL] And that was uh [PII] and we did pay that benefit um and so there's that one and then again this is all looks like just from a little bit ago today uh and then I've got another, let's take a look at this one.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] That is also from um Aus Medical Center um so we did pay those benefits it most of the time with that kind of um where it's pending that information it could mean a couple of different things. One is that we're needing, you know, if the group or your employer is undergoing their renewal period in which case everything is kind of put on a hold until that information goes through. The other is similar where it's um what they call verifying eligibility.
[CUSTOMER][NEUTRAL] Right, but this has been going on since January, so.
[AGENT][NEUTRAL] Yes, and it really does depend on how quickly we can.
[CUSTOMER][NEUTRAL] Right, this has been going on since January.
[AGENT][NEUTRAL] Right, and it does depend on how quickly we can get that information, um, and I do apologize for the wait, but again this inform that did just finished reprocessing, um, so it this information is good to go. Let me double check really quick to see if there were any others.
[CUSTOMER][NEUTRAL] Oh, there's many others.
[AGENT][NEUTRAL] Oh, OK, let's take a look.
[CUSTOMER][NEUTRAL] And I mean, I understand sometimes they submit, you know, like doctor office visits, they they'll submit that and I understand those are not covered.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] You know, I'm not worried about those, the doc the office visits. Um.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] [PII]'s coming after me now.
[AGENT][NEUTRAL] Sure. OK, let's take a look. Right.
[CUSTOMER][NEGATIVE] For the money because they're tired of waiting since January.
[AGENT][NEUTRAL] Understand, um, so, OK, a lot of them, and this is where it can get a little bit more confusing as well the ones that say pending are not truly denied um again it's just one of those things once we have that information like what just happened today where they can continue processing and have been approved. I do see one that denied is that was an office says it so bear with me and let me try to see if I can't find anything else kinda out of the ordinary.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Yeah, I'm not, yeah, it's like $55 office visits. I'm not worried about those.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, and then I do have some that the benefits applied went to your deductible for this policy. You have a $100 deductible um and this was, let's see.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Uh, let me go back.
[CUSTOMER][NEUTRAL] That was beginning in January. But it's like, y'all.
[AGENT][NEUTRAL] So this one actually processed before I know it's a bit confusing um this one is well that that might have been.
[AGENT][NEUTRAL] This data service that was [PII] and that was uh $63.13.
[CUSTOMER][NEUTRAL] Right, so why would some after be applied to a deductible but yet things before being before and after the deductible or being.
[AGENT][NEUTRAL] Mhm it depends on, yeah, it depends on when we get it so yeah and it really does depend on when that oh I'm sorry, yeah go ahead.
[CUSTOMER][NEUTRAL] You know, it, it
[CUSTOMER][NEGATIVE] Well, no, I, I, I mean, I understand what you're saying, but I'm just truly not buying it at this point because this has been going on since January.
[CUSTOMER][NEGATIVE] And it needs to be resolved because I'm getting a lot of bills and now and now [PII]'s coming after me. And this is the whole point of having this insurance.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Yeah absolutely and like I said this information does look like these two I see right now that have just completed processing today um and those are the ones that we did pay so it looks like that is complete, um, so I'm not I'm not sure what other um what kind of information are you needing.
[CUSTOMER][NEUTRAL] Is to help cover all these costs.
[CUSTOMER][NEUTRAL] Oh, I got 10 of these notices from you guys over the weekend in the mail from [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, we're from [PII], and it looks some of it looks like it's duplicates over and over again.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] [PII], um, so it, I mean, but it's all got different dates on it from y'all, it's like the date that y'all are processing this is all the different dates, but yeah, y'all just still keep not processing the coins.
[AGENT][NEUTRAL] And those are the ones that just went through.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] They did, uh, and again I apologize for that confusion. I do have these two, like I said, that did just complete processing today, so I'm that's the mail can be what who knows when those were sent, you know, and I'm so sorry that that added to the confusion, um, but like I said, I do see that these did complete. Sorry?
[CUSTOMER][NEUTRAL] [PII] again.
[CUSTOMER][NEUTRAL] That was this month in May.
[CUSTOMER][NEUTRAL] They were sent out this month. I mean, as late as [PII].
[CUSTOMER][NEUTRAL] As late as [PII] they were sent out.
[AGENT][NEUTRAL] I'm trying to think, let's see because that's when we did receive some additional information, yeah.
[CUSTOMER][NEUTRAL] You know, which is after it.
[CUSTOMER][NEGATIVE] You know, and it, you know, I, I just don't understand because like y'all have been called multiple times about this.
[CUSTOMER][NEUTRAL] And there, there's coverage, I mean, correct?
[AGENT][NEUTRAL] Yes, again during that period where it was showing that it was pending, it can mean a lot of different things if you'd like a deeper look into that clarification what that exact information was that's what we were waiting for was information from uh your group and or your uh employer.
[AGENT][NEUTRAL] And once we had that it completed processing or if it was the group as a whole that was going through a renewal, everything is kind of put on hold until that information goes through and in which case it looks like it just did because it's all processed now.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Alright, so if I go online.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] And look at the EOBs, it's gonna start showing that these claims are processed.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Yes, so for example I can give you there's.
[CUSTOMER][NEGATIVE] Because it's, it's very confusing.
[AGENT][MIXED] It is very confusing. You are absolutely right.
[CUSTOMER][NEGATIVE] To me, because I'm getting bills from [PII]. I'm getting, you know, Blue Cross pays however much and then APL is supposed to pay and then I'm left with the difference. And it's very confusing when everything just keeps getting denied. And I'm, I'm saying denied. I know you're saying pending, but to me it's denied because
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Sure, um,
[AGENT][NEUTRAL] No, no, no, I know what you mean.
[AGENT][NEUTRAL] Not paying, I understand, yeah, I know what you mean.
[CUSTOMER][NEGATIVE] You know, I'm stuck owing the bill.
[AGENT][POSITIVE] Yes, exactly.
[CUSTOMER][POSITIVE] And you know, right now, I'm, I'm just, you know, I, I got a lot going on and I definitely don't need this headache.
[AGENT][NEUTRAL] Sure.
[AGENT][POSITIVE] Absolutely, I understand. Um, let's see, let's do this, um.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Give me just a moment, um, because again I see these two and so like if you were to go on the website like right now at this second you would see these two claims probably right up top because they're gonna be the newest ones where they have been reprocessed so you might still see those original ones that are saying that they're pending um this is the same information again both of these were from that um Ausner clinic well one was different I think Ausner or something, um, but they were both from, uh.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII], um, so this one we paid a benefit of $489.56 and then this other 10 goodness.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] See that was, uh, we paid a benefit uh oh this one was medical center, um, and that was $1,741.57 so it's just issued again just today so if you would like, I mean I know you said that there's been already a lot of phone tag and um.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] But you know if they need any clarification this claim number anything like that they should be getting that the EOB soon as it just finished uh but if they need any immediate information to know that it did indeed pay, um, so that you know they stop driving you nuts, um, they're more than welcome to give us a call so we can pass this information along to them.
[CUSTOMER][NEUTRAL] OK, I'm gonna give it some more time. And what about the claims after [PII]?
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Let's see, give me just a moment. It was ones that I was kind of looking at.
[CUSTOMER][NEUTRAL] Because [PII] I think was the initial, oh yeah, there, there's a lot.
[AGENT][NEUTRAL] Oh, there were several. Let's take a look.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I'm trying to see here.
[AGENT][NEUTRAL] So after the [PII], let's see, oh that was December.
[AGENT][NEUTRAL] There's more from the [PII].
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] Bear with me just a moment.
[AGENT][NEUTRAL] Uh an office visit. Let's see.
[CUSTOMER][NEGATIVE] I know it's gonna be 42 42 47 I mean 57 512. I have problems.
[AGENT][NEUTRAL] Here's
[AGENT][NEUTRAL] Let's see, let's see, here's [PII], and that one again went towards your deductible. So let's see, there's a couple that went towards deductible.
[AGENT][NEUTRAL] OK, yeah, that was those two, couple from March, couple from February.
[CUSTOMER][NEUTRAL] Yeah, I had only seen so far going to work deductible was $63.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] There was another one as well. This is the one that I just saw that was uh 19, um, this was from uh [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] That went towards your deductible as well.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. Office visit, office visit. What's the one?
[AGENT][NEUTRAL] That's that one from [PII].
[CUSTOMER][NEUTRAL] Yeah, no matter how many times I tell them don't submit offices they still do.
[AGENT][NEUTRAL] I'm gonna, I'll see.
[AGENT][NEUTRAL] Well, and that might be again all providers they might need that kind of um paper trail, you know, showing that this is indeed the denial reason, you know, um, so it is a little bit adds to the confusion but it's all right. OK, so it looks like again I believe what I think's happening because I see these two right now so it looks like all of these other clients there were.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] 4 there were 4 claims that were in that pending status, so let me check those dates.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] There's one another one from [PII].
[CUSTOMER][NEUTRAL] I don't even remember what happened on March.
[AGENT][NEUTRAL] Here's April. [PII], quite a bit from April, um, let's see, let's check this other one.
[CUSTOMER][NEUTRAL] Yeah, that's gonna be.
[CUSTOMER][NEUTRAL] A big one.
[AGENT][NEUTRAL] That one, another one from [PII].
[AGENT][NEUTRAL] OK, so yeah, [PII] and [PII] looks like.
[CUSTOMER][NEUTRAL] Yeah, and it should be like I think [PII] or something.
[AGENT][NEUTRAL] So I've not received that one yet. Uh, the last claim from the, the last date of service that we received was this, um, [PII], so it looks like those are the ones that are kind of coming up next, uh, for being reprocessed, um.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And that I imagine that'd be happening shortly since these are.
[AGENT][NEUTRAL] These ones are just fresh off of the board it looks like.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. I'll, I'll give it another week or two and check back again.
[AGENT][NEUTRAL] Sure.
[AGENT][POSITIVE] Sure. I'm sorry about all the confusion. I know it's, it's quite a bit. Mhm.
[CUSTOMER][NEGATIVE] And see because like I said [PII] sending me, well I mean I've never had this problem before so I don't know why it's exactly it's happening now.
[AGENT][NEUTRAL] Yeah, a lot of the time.
[CUSTOMER][NEGATIVE] But it's just not a good time to be happening.
[AGENT][NEUTRAL] No, I, and I completely understand, um, and I'm not 100%, um, what with all of the group information and that's not I see kind of surface level, um, but I do know most of the time with that it's either they're going through a um a renewal phase and that can certainly take some time if it's a larger group, um, if they take you know all of the information they have to get us and stuff and so while that's happening a lot can be kind of put on hold for a minute you know.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, well, like I said, it's been going on since January, so I don't know that it should take half a year for it to renew.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] It can certainly take, I've seen it take a while before, but again, it's, you know, one of those things a lot kind of goes into it.
[AGENT][NEUTRAL] But it sure looks like the ball is rolling now.
[CUSTOMER][NEUTRAL] OK. I'll
[CUSTOMER][POSITIVE] All right, I'll give it some more time then.
[AGENT][NEUTRAL] Yes ma'am all right did you have any other questions for me at the moment?
[CUSTOMER][NEUTRAL] OK. All right.
[CUSTOMER][POSITIVE] Uh, no, that was all I needed. Thank you.
[AGENT][POSITIVE] Alright, yes ma'am, thanks for giving us a call have a great rest of your day.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] Thank you bye bye.
[CUSTOMER][NEUTRAL] Bye bye.