AccountId: 011433970860
ContactId: b0dc026b-b18a-4752-a3d9-98abe06efe92
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 641000 ms
Total Talk Time (AGENT): 309645 ms
Total Talk Time (CUSTOMER): 224616 ms
Interruptions: 1
Overall Sentiment: AGENT=0.6, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/14/b0dc026b-b18a-4752-a3d9-98abe06efe92_20250114T21:59_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] And um, I'm gonna be transparently honest with you.
[CUSTOMER][NEGATIVE] And I am stressed out.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] And uh, I'm a hardworking society, uh, supporting member of society, and, and I don't have $4000 to, to just to allow, just to offer.
[CUSTOMER][NEUTRAL] I, um, I got knee surgery, um.
[CUSTOMER][NEUTRAL] I have gap insurance allegedly and that's where I'm going right now.
[CUSTOMER][NEGATIVE] And, and I don't know how to get the award to pay this back.
[CUSTOMER][NEGATIVE] With my old company with Aflac, if this was Aflac, I would have had my money months ago. So I need somebody to tell me what it is that I need to say because I've already turned in 4 claims and you all keep refusing me and I don't know what to do, but I need my money.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] OK. Well, I can definitely take a look at the policy and the claims and see what's going on, if something's needed, um, I can look into it and we'll see what we need to do to file a claim, um, but you're definitely in the right place and I'll be more than happy to help you.
[AGENT][NEUTRAL] Um, you're welcome. Well, 1st may I have your name and a good contact number in case we're disconnected?
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] My name is [PII]. My contact number is [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you for that. And Mr. [PII], may I have your policy number?
[CUSTOMER][NEUTRAL] My policy number is 4241.
[CUSTOMER][NEUTRAL] 976 8
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] OK, I have you here and I just need you to verify your date of birth, your mailing and email address on file.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Uh, [PII], then in [PII] [PII]
[CUSTOMER][NEUTRAL] [PII] [PII] [PII].
[AGENT][NEUTRAL] All right, and all the information provided is a verification of benefits, not a guarantee of payment. So off just from looking at the claims, um, there's two things. So,
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] The first claim, there was a claim that was submitted on [PII]. Actually, this has the same claim number, um, claim number.
[CUSTOMER][NEUTRAL] There was a claim that was
[CUSTOMER][POSITIVE] That's correct.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] All of them the same. I only had one thing, knee surgery.
[AGENT][NEUTRAL] Right, but every time something is submitted, it's a different claim number that's generated. So I'm gonna let you know.
[CUSTOMER][NEUTRAL] Oh yeah.
[AGENT][NEUTRAL] So I'm gonna give you the claim number and then I'm gonna tell you what they're asking for on each of the claims. I see where you tried.
[AGENT][NEUTRAL] To submit, um, but those after the denial, but it was denied as a duplicate. So I'm just gonna give you everything you're looking for.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] You're welcome. Um, so let me know when you're ready.
[CUSTOMER][NEUTRAL] Alright.
[AGENT][NEUTRAL] OK. So for um claim number 353-8814.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] They're asking for two things. Anytime a claim is filed, you're gonna need the explanation of benefits from your primary insurance.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] You're gonna need the itemized bill. OK.
[CUSTOMER][NEUTRAL] Hold on, hold on, hold on.
[CUSTOMER][NEUTRAL] Explanation of benefits.
[AGENT][NEUTRAL] Uh, from your primary insurance.
[CUSTOMER][NEUTRAL] From primary insurance OK.
[AGENT][NEUTRAL] So, um, you'll just call that member services number on the back of your card and ask them for, I'm going, let me get all the dates of service. This looks like [PII] and [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So, um, and they'll usually email that to you and then you can just upload it onto the online service center.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So, all of the claims that you filed so far are asking for the explanation of benefits from primary insurance.
[AGENT][NEUTRAL] And the diagnosis code. Now, that comes from the itemized bill.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The itemized bill comes from the doctor or the hospital that you went to. So you'll just um reach out to their billing department and ask for an itemized bill.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] Some places call it a universal bill, but it's the same thing.
[CUSTOMER][NEUTRAL] OK, let me ask you something. Can you see what I put in? OK, go ahead, I'm sorry.
[AGENT][NEUTRAL] But
[AGENT][NEUTRAL] Oh, it's OK. But on the bill, you'll need the diagnosis codes.
[AGENT][NEUTRAL] The procedure code.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then, of course, it'll show all the charges.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And you want me to take a look at what was sent in?
[CUSTOMER][NEGATIVE] Right, because I did one. I thought I had the itemized bill. You tell me what's wrong with that one.
[AGENT][NEUTRAL] Let me see if it
[CUSTOMER][NEUTRAL] I sent.
[AGENT][NEUTRAL] Oh, go ahead. I can hear you still.
[CUSTOMER][NEUTRAL] 1355-0697.
[CUSTOMER][NEUTRAL] Claim number 355-0697.
[AGENT][NEUTRAL] Hold on 1 2nd.
[AGENT][NEUTRAL] You're saying you sent the bill with that claim?
[CUSTOMER][NEUTRAL] I forgot to
[CUSTOMER][NEUTRAL] Yeah, what's your name?
[AGENT][NEUTRAL] My name is [PII].
[CUSTOMER][NEUTRAL] Yeah, OK, I thought so, right.
[AGENT][NEUTRAL] Yes, sir.
[CUSTOMER][POSITIVE] OK, I got you now right down.
[AGENT][NEUTRAL] OK. Hold on one second. Let's see.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So what you're submitting is your patient bill. So basically your bill is created from the big bill that we're asking for, but on your bill, it only shows like the the procedure code or the treatment that you received. We need the diagnosis codes to prove the medical necessity for the treatment that was received, so that we can pay out.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so how, how do I, OK, so what, tell me what I need to ask for.
[AGENT][NEUTRAL] Oh, once you call the doctor's office, just ask them for an itemized bill.
[AGENT][NEGATIVE] Or they may call it a universal bill, but just stress to them that it needs to be their copy that has the diagnosis and procedure codes and charges on it.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Because that's why these um
[AGENT][NEUTRAL] That's why these claims have been denied the explanation of benefits and the coding.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then as soon as we receive those bills and the um explanation of benefits, I would even send one, is this the same date?
[AGENT][NEGATIVE] Oh yeah, this is all [PII]. I will even send it for the surgery because that one has been denied for um needing an explanation of benefits.
[CUSTOMER][NEUTRAL] I do the same.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So OK, so this, so, OK, so let me ask you something. So when I go through all of that and I go, do I have to go back to the claim forms?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Oh no, you don't have to do the claim forms again because they are already asking for the additional information, so once they receive it, they'll be able to see where it, you know, it's, this is for this claim and go ahead and continue processing.
[CUSTOMER][NEUTRAL] So the only thing I need to do is send the explanation of benefits of primary insurance and send the universal itemized bill, the doctor's copy.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] With the procedure code on it, the diagnosis code, the procedure code and all charge codes.
[AGENT][POSITIVE] Yes, that's correct.
[AGENT][NEUTRAL] And then they can go ahead and process the claim.
[CUSTOMER][NEUTRAL] And it's uh.
[CUSTOMER][NEGATIVE] That sounds so easy, and you got me, I, I can't even get excited no more, and I'm so hurt. Right before [PII], I got hit with $4000.
[AGENT][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] You say how you feel my pain.
[AGENT][NEUTRAL] I felt that when you said 4000 the first time.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Exactly, yeah, that's all my hard work money. I didn't use no credit card use money.
[AGENT][NEUTRAL] Well, yes, I would definitely get all this in so you can um get your reimbursement. But now, if you do have to file any other claim so that you don't run into this, just go ahead and submit the claim, make sure it has the form, the bill, and the explanation of benefits every time.
[CUSTOMER][POSITIVE] OK, well, I go to therapy Thursday, so I'm gonna get everything. I'm gonna tell him I'm not leaving here until you give me this stuff. Thank you so much.
[AGENT][POSITIVE] You're very welcome. Well, was there anything else I can help you with today?
[CUSTOMER][NEUTRAL] Yeah, you could, you could tell me that you're gonna send that money in my direct deposit if you wanna do something for me.
[AGENT][NEGATIVE] I wish I could, but I don't know where to get it from.
[CUSTOMER][NEGATIVE] OK, well then you don't get it from them people because they take it out my check, so I want, I want my money back.
[AGENT][POSITIVE] Yeah, and as soon as we get the documents, we'll go ahead and um process these claims and get you your funds.
[CUSTOMER][POSITIVE] Thank you so much and I appreciate you. Have a good day, OK.
[AGENT][POSITIVE] You're very welcome, Mr. [PII]. You also, well, thanks for calling APL. I hope you feel better and um have a good evening and happy New Year.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] Thank you. Bye-bye.
[CUSTOMER][NEUTRAL] Bye bye.
[CUSTOMER][NEUTRAL] Man, they make it sound so