AccountId: 011433970860
ContactId: af0bb10a-80fa-4ec7-b5eb-8eec51f0a4b7
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 595219 ms
Total Talk Time (AGENT): 335734 ms
Total Talk Time (CUSTOMER): 301330 ms
Interruptions: 12
Overall Sentiment: AGENT=0.8, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/19/af0bb10a-80fa-4ec7-b5eb-8eec51f0a4b7_20250519T22:42_UTC.wav
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[AGENT][POSITIVE] Thank you for calling CTL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Hi, um I am reaching out about a claim that's the explanation of benefits for a policy that I have been kind of challenging for a few months now since my daughter was born, and I was gonna see if I could chat with someone about it.
[AGENT][NEUTRAL] OK, um, regarding a claim that you'd already filed and it's been denying or are we needing just missing information regarding it?
[CUSTOMER][NEUTRAL] Well,
[CUSTOMER][NEUTRAL] It says it's a duplicate claim, but I needed to talk to someone about it because, so the, the claim is, is I had my daughter [PII]. And we had an inpatient expense that's supposed to be covered under our benefits on the [PII], the [PII], and the [PII]. Well, they billed the [PII] appropriately. So APL covered it like, like they would from the same regional pediatrics group.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Well, on the [PII] and the [PII], I had to call them and tell them to resubmit it appropriately, not as a insurance primary claim. And then I got these that says this is a duplicate claim. So,
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] The problem is, we know that the benefit covers it because they paid for the doctor on the [PII] as an inpatient expense and now the [PII] and the [PII] keep getting, I don't know, I wouldn't say denied it just says, yeah.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEGATIVE] Oh gosh, what a mess. OK, yeah.
[AGENT][NEUTRAL] No, yeah, there's something mixed up. OK, we'll definitely take a look at that and see what's going on. um, what was your name? I'm sorry.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] My name is [PII] and I do you have my policy number or the reference number right here on this paper.
[AGENT][NEUTRAL] Sure, you can go ahead and give me that.
[CUSTOMER][NEUTRAL] Uh, the reference number?
[AGENT][NEUTRAL] Uh, the policy number, please.
[CUSTOMER][NEUTRAL] Or a policy.
[CUSTOMER][NEUTRAL] OK it is 01894727.
[CUSTOMER][NEUTRAL] And something else I noted that's strange is the patient account number has a an additional letter so like on this paper I'm looking at from the [PII], the patient account numbers are different because there's one letter missing.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um, a letter, uh, with the.
[CUSTOMER][NEUTRAL] So I thought that was strange too.
[AGENT][NEUTRAL] Um, but I, I don't know. Yeah, we'll take a look. OK.
[CUSTOMER][NEUTRAL] Like, like, OK.
[AGENT][NEUTRAL] Sure, no worries. Alright, I'm just gonna verify some information really quick, uh, [PII], can I get your date of birth please?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mine is [PII], but the policy.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Got you. I appreciate that um can you verify the uh mailing address that we've got on file please?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Got it. And then the last thing I need is the email address that we've got on file for y'all uh looks like it is a Gmail account.
[CUSTOMER][NEUTRAL] Oh, it may be [PII] or [PII].
[AGENT][NEUTRAL] It is [PII], OK, yeah, thank you for verifying all of that. OK, let's take a look here and this was for uh [PII]?
[CUSTOMER][NEUTRAL] OK, yeah, it makes sense, OK.
[CUSTOMER][NEUTRAL] Yes, [PII] on [PII] was the day she was born.
[AGENT][NEUTRAL] Got it. OK, give me just a moment.
[CUSTOMER][NEUTRAL] So my thoughts are, is if somebody can look at the [PII], however, that was billed as how it needs to be done. And I can tell, you know, the regional peace group to straighten it up and they need to get it right the [PII] time.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] No worries. OK, so I do see there's the one from the [PII], and then I do see a couple from the [PII], so it looks like we did get those. Now give me just a moment. Let me take a look here. We paid on the [PII] we did pay a benefit of $67.14 so I'm wondering.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] That, yeah, see, that's what I don't understand.
[AGENT][NEUTRAL] But it is a different amount of basement though.
[AGENT][NEUTRAL] Hm.
[CUSTOMER][NEGATIVE] And then the [PII] is a huge charge but it makes no sense, um, at all. I just don't understand.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] Oh, OK, well, here we go. Alright, so I did find those original claims all right, so we did receive the ones from the [PII] um it looks like there was one charge for $150.82 and another for $116.36 which we did pay. Let me pull that one up. Give me just a moment.
[AGENT][NEUTRAL] Yeah, so that one for the [PII] we paid a total benefit of $267.18 so that might be that was the original claim.
[AGENT][NEUTRAL] And let me take a look here.
[CUSTOMER][NEGATIVE] So they sent me a bill for 575 saying that nothing there was nothing on file.
[AGENT][NEUTRAL] See, and that's what's odd is that I do see that one and let me see if that's the one that's registering as a duplicate because it is a different amount so I'm wondering if they didn't send.
[AGENT][NEUTRAL] Accurate information over give me just a moment.
[CUSTOMER][NEUTRAL] That's what I'm guessing. And when I look at the [PII], the patient number 1 has at the end, 9 XRNA and then the one below it says XNA like they messed up and forgot one or I don't know.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Oh, I do see that.
[AGENT][NEUTRAL] Interesting and that that's not usually something that affects us um that's usually more them like the patient account number is going to be all through them like that's the account number that you know y'all through them so that's not a huge deal as far as us but that's what I'm wondering here's what I recommend can just for the sake of simplicity um I would have them because you haven't, have you paid any of these bills yet?
[CUSTOMER][NEUTRAL] So I'm wondering if they billed me the wrong amount.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] But they've sent you
[CUSTOMER][NEUTRAL] No.
[AGENT][POSITIVE] Awesome, OK.
[CUSTOMER][NEGATIVE] No, because I, I've done this in the past and it's hard to get you guys what we pay and get reimbursed for it. Um, and, and they paid for the 13th, and so I thought somebody's just screwed something up.
[AGENT][POSITIVE] Yeah and that's what I was going to recommend is.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, well, they did pay.
[AGENT][NEUTRAL] Right, they do. I do still payments for every day. I do see payments for the [PII], [PII], and the [PII].
[CUSTOMER][NEUTRAL] Uh huh.
[AGENT][POSITIVE] Well, I've got, oh goodness.
[AGENT][NEUTRAL] Let's see [PII]. Let me see this one real quick because this is a different one as well.
[CUSTOMER][NEUTRAL] It's OK.
[AGENT][NEUTRAL] OK, so this other one for the [PII], um, because again we did pay a benefit on the [PII] for $67.14 but there was another one after that for $125 that registered as a duplicate. So what I think we should do, um, unfortunately, um.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] All of our claim specialists are out for the night. Um, we, we're only open for about 10 more minutes. So what I would recommend doing is getting a hold of the provider, letting them know that you did speak with us regarding this and really encourage them to give us a call. We talk to providers all the time that way you're not.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Stuck in the middle with all this he said she said we can get straight to the root, let them know what we received and try to pinpoint what the problem is, you know, and that way we can just get all of this resolved obviously they wanna get paid so I don't think there would be any problems with that but that way you know it's there's nothing that you would have to go ahead I'm sorry.
[CUSTOMER][NEUTRAL] Sure. Yeah.
[CUSTOMER][NEUTRAL] So, I definitely, yeah.
[CUSTOMER][NEUTRAL] I definitely dabble in the world of medical billing so I kind of understand what's going on. I just wanted to know if this if this is a completely different claims isn't it? They're not even the same ones that they're submitting for.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] For approval.
[AGENT][NEUTRAL] What do you mean? I'm sorry.
[CUSTOMER][NEUTRAL] Because if you guys paid $60 well, you said that we had paid, you had paid for one of the claims on the [PII] of $60 something dollars, but then I've got a different charge entirely for $125.
[AGENT][NEUTRAL] That was the [PII], yes.
[AGENT][NEUTRAL] Yes, and that's where sometimes um it can get extremely confusing again depending on the provider what they send you um versus what we get as this is the secondary medical policy, what they're supposed to bill us is the remaining balance after the primary paid so it's anything left over from a copay deductible or co-insurance.
[CUSTOMER][POSITIVE] Interesting.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Co-pay.
[CUSTOMER][NEUTRAL] Yeah, and I think it looks like they're not billing you that.
[AGENT][NEUTRAL] Well, and that's where I think it's mixed up.
[CUSTOMER][NEUTRAL] Yeah, it looks like they're billing you originals.
[AGENT][POSITIVE] Yes, exactly and so that's what I'm, I, I just think you know we ought to talk to them and figure out what's going on with us, you know, so get all of that squared away for you.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] And you know, I have
[CUSTOMER][NEGATIVE] I went through this with them and I told them that and I, and because the original rejection from you guys is we don't benefits don't cover um insurance claims. I was like, oh my gosh, OK, so the Blue Cross Blue Shield copays did not get taken into account. They're just billing it so wrong. Anyway, OK, I will reach out to them and let them know to reach out to you guys. So is the number that I just called the most accurate?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right, right.
[AGENT][NEUTRAL] I would just, yeah.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] That's it.
[AGENT][POSITIVE] Absolutely yes um so yeah and again let them know that way that that you did speak with us it'd be easier on everyone if they just gave us a call so we can get this resolved for you and for them.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][MIXED] I will do it and I appreciate it very much um because I just can't seem to figure out why in the heck.
[AGENT][NEUTRAL] All right.
[AGENT][POSITIVE] You're very welcome.
[AGENT][NEUTRAL] I know, it's
[AGENT][NEUTRAL] It's a lot. You got a little baby and the last thing you need to worry about is this back and forth, so.
[CUSTOMER][NEUTRAL] They can't ever bill yeah.
[CUSTOMER][POSITIVE] OK, well, I appreciate it. Thank you.
[AGENT][POSITIVE] Yeah, absolutely. Was there anything else I can help you with?
[CUSTOMER][NEUTRAL] Um, is there,
[CUSTOMER][NEUTRAL] Is there any way I could give them a reference name to, you know, reach out to you since we've already spoken or does it matter who picks it up?
[AGENT][NEUTRAL] You can. I mean it really doesn't honestly, um, because I couldn't, I don't have a direct line and I can't, you know, 100% that I would be available but you can they can say that you know we spoke and of course I will be notating y'all's account um so anybody if somebody else gets it besides me they'll have record that I spoke with you regarding this.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Perfect, perfect. OK, well I appreciate it and I will reach out to them at lunch tomorrow and see what I can figure out.
[AGENT][POSITIVE] Absolutely.
[AGENT][POSITIVE] Sounds good. All right. Well, I hope you have a great rest of your day, [PII]. Of course. Thank you.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] You too. All right, thanks, bye bye.
[AGENT][NEUTRAL] All right, bye-bye.