AccountId: 011433970860
ContactId: b12d3b49-406f-47c7-81b7-38c31e7cb074
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1253489 ms
Total Talk Time (AGENT): 350534 ms
Total Talk Time (CUSTOMER): 655408 ms
Interruptions: 3
Overall Sentiment: AGENT=0.7, CUSTOMER=-0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/01/b12d3b49-406f-47c7-81b7-38c31e7cb074_20250501T13:08_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yes, I have questions about a declined claim.
[AGENT][NEUTRAL] OK. I'm happy to check on the claim. Um, is it a claim of yours? Are you the insured?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, what's the claim number or policy number if you have that?
[CUSTOMER][NEUTRAL] Kick me out just.
[AGENT][POSITIVE] No problem.
[CUSTOMER][NEUTRAL] 002.
[CUSTOMER][NEUTRAL] 5274441
[AGENT][POSITIVE] Alright, thank you so much. Let me just pull this up here.
[AGENT][NEUTRAL] And if I could get first name, last name, and date of birth on the policy.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Um, what did you say full name, what else?
[AGENT][NEUTRAL] Uh, date of birth, please.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. And then if you could lastly verify the address on file.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Um, [PII].
[AGENT][POSITIVE] All right, thank you.
[AGENT][NEUTRAL] Uh let's see here.
[AGENT][NEUTRAL] And was it a recent claim? Was it under your name or the other insured?
[CUSTOMER][NEUTRAL] It's under, it was filed under my husband.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Me.
[CUSTOMER][NEUTRAL] And it's like,
[CUSTOMER][NEGATIVE] It doesn't matter what happens, what I'm saying, you all have decided that now at this point I'm taking it personally. Every time I put in a claim it's denied, and I always have to call and say something for it to be approved.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEGATIVE] This denial says you need an EOB. I gave you two EOBs, so why do I need another EOB?
[AGENT][NEUTRAL] OK, let me just look at the claim here while it was submitted. I see that.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] It's just taking a minute to load. I appreciate your patience. I'm just checking all the pages that were sent.
[AGENT][NEUTRAL] OK. Um, yeah, I see down towards the bottom, it was like pages 1112.
[AGENT][NEUTRAL] The explanation of benefits so um I can call over to claims and get somebody on the line, have them double check this or I can have somebody in claims call you back.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEGATIVE] No, I hope cause no one ever calls back, but it doesn't make sense, so a person they claims can't read, they shouldn't be working here. This is the 2nd time it's been denied and you have the documents. The 2nd time.
[AGENT][NEUTRAL] I'm sorry.
[CUSTOMER][NEGATIVE] I haven't even filed a claim because I didn't feel like dealing with this, but I gave you what you asked for and you're telling me you still don't have it, so apparently someone has a reading comprehension issue cause this makes no sense.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] OK. Um, I'm happy to.
[CUSTOMER][NEGATIVE] So no, I'm not gonna, I'm not gonna wait for a call back. I, I'll wait for you to get someone on the line because I would love to know why if the EOB says 39, you're telling me you don't have it for 39 319.
[AGENT][POSITIVE] Yeah, not a problem.
[AGENT][NEUTRAL] OK, yeah, absolutely, um, is this number you're calling from a good callback number if anything happens on the transfer?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, uh, just one moment please.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hey, [PII], it's [PII] in customer care. How are you this morning?
[CUSTOMER][POSITIVE] I'm doing well, [PII] how are you?
[AGENT][POSITIVE] I'm good. It's early, girl.
[CUSTOMER][NEUTRAL] It is, it is. I know the phone rang and I was like, oh, getting started early today, OK.
[AGENT][NEUTRAL] Uh no, it's too, it's too early for all this. OK. Anyhow, um, I have an insured on the line. She has a question about a claim, and so I can give you the policy and claim number when you're ready.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, go ahead.
[AGENT][NEUTRAL] Uh, policy is 02527441.
[CUSTOMER][NEUTRAL] Part one
[AGENT][NEUTRAL] Um, it's for part two, [PII].
[CUSTOMER][NEUTRAL] Part 2, OK, and what's that claim that we're looking at?
[AGENT][NEUTRAL] Yeah, and
[AGENT][NEUTRAL] 359.
[AGENT][NEUTRAL] 6099.
[AGENT][NEUTRAL] So claim was denied for EOB. I did check on base. I see an EOB now I'm not a claims examiner so I could be missing something.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] Um, she's frustrated cause she says they're always denied and she's like, I attached the EOB. I don't know what else you guys need.
[AGENT][POSITIVE] So, if I'm missing something, please, yeah, enlighten so I can.
[CUSTOMER][POSITIVE] Got you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] You know I will, [PII], you know I will.
[AGENT][NEUTRAL] Cause I will educate. I, no, yeah, no, I'll educate and be like, hey, you know, this, this and this is, you know.
[CUSTOMER][NEUTRAL] I'll be like hang on, girl.
[CUSTOMER][NEUTRAL] Yeah, let me see what we have because it's.
[AGENT][NEUTRAL] Uh.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Quite a date span, um, I mean that's nearly a month's worth of chemo so let me see what we have and why they request wonder if they put an EOB not. Did they put an EOB note on there by chance? Do you know?
[AGENT][NEUTRAL] Um, let's see.
[CUSTOMER][NEUTRAL] I mean, I don't, I don't think they did.
[AGENT][NEUTRAL] I don't think so either.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] Let's see
[CUSTOMER][NEUTRAL] OK, so we have the hospital stay and where they highlighted the chemo, so let me go in here and see.
[AGENT][NEUTRAL] If I see
[CUSTOMER][NEUTRAL] OK, and then there's 3:19.
[AGENT][NEUTRAL] Yeah, cause at first I just saw 3-19, but then I was like, oh, I saw February and I was like, OK.
[AGENT][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK, let's see.
[CUSTOMER][NEUTRAL] So this.
[CUSTOMER][NEUTRAL] Hang on, let me, let me finish looking because I don't, I'm only on like page 10 so I don't wanna be like this looks like without like really looking and determining what's going on here, OK.
[AGENT][POSITIVE] No, no worries.
[AGENT][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So 319 labs.
[CUSTOMER][NEUTRAL] Drugs, drugs, oh, you know what? Let's do this.
[CUSTOMER][NEUTRAL] I need to see how much those two things cost. OK, so for 227.
[CUSTOMER][NEUTRAL] We had a cost of 33,060.
[CUSTOMER][NEUTRAL] And then for 319, so it's not actually a huge date span it's just two different dates and they put it in there as a date span, which is fine. It can just be a little misleading sometimes. OK, so 4:39 20. Alright, now let's go to these EOBs attached because that's gonna be the kicker is associating those calls with because the thing is is that a lot of times on EOBs they don't actually put the name like they do.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] On the bill and then you have to be like OK I have to associate this cost with this charge right so I see 33,060.
[AGENT][NEUTRAL] Um.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] It looks like.
[CUSTOMER][NEUTRAL] It looks like there wasn't anything paid. Let me see if there's any remark codes.
[CUSTOMER][NEUTRAL] Um, you pay $0. Here's the breakdown.
[CUSTOMER][NEUTRAL] Hospital charges, your discounts due to your hospital and then what anthem paid.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So hospital costs for that one were 3.
[CUSTOMER][NEGATIVE] Uh, due to your hospital's 360 Anthem paid nothing.
[CUSTOMER][NEUTRAL] Co-pay, deductible, co-insurances service is not allowed also nothing.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] You don't pay the your discount amount. This is the benefit to using doctors facilities in our plan.
[CUSTOMER][NEUTRAL] I mean, it looks like Anthem paid them.
[CUSTOMER][NEUTRAL] What all the allowed amounts, it just isn't listed right there, um.
[CUSTOMER][NEUTRAL] So I see that I'm gonna.
[CUSTOMER][NEUTRAL] Hold on
[CUSTOMER][NEUTRAL] Let me see where this is at.
[CUSTOMER][NEUTRAL] Because I see that it's denied, but it looks like it.
[CUSTOMER][NEUTRAL] May it hasn't been completed out of the system so I'm trying to.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It's done yesterday.
[CUSTOMER][NEGATIVE] But it wasn't completed out of the system which is unusual.
[CUSTOMER][NEUTRAL] OK, um, that could have just been an error by the examiner, um.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, so I'm going to actually highlight this.
[CUSTOMER][NEUTRAL] Because I'm not.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] Truthfully this may be something no that was the wrong highlights.
[AGENT][NEUTRAL] This may have been a a boo boo one.
[CUSTOMER][NEGATIVE] Wrong charge.
[CUSTOMER][NEUTRAL] It may have been the thing is is that so what we what we do when we're looking at these for cancer policies is when we're looking at actual charges which is what this policy is looking at um we look at what your insurance paid.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And what your responsibility is and then typically those two numbers combined are what your actual charges are like we don't look at that the charge amount because that would be looking at build charges and there's a difference when we're looking at cancer policies because some go by build and some go by actual charges so the actual charges are after all the discounts and write offs and whatever.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] What they paid versus what you owe is what you like what we're gonna pay, they have the allowed amount, but they're not showing that they paid anything and they're not showing that.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] The insured owes anything which is probably even there is an EOB she's not, she's not wrong about that. There is an EOB um what I'm guessing and I'm not 100% on this, um, I would have to speak to the examiner or maybe even another auditor is they.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Like they don't um.
[CUSTOMER][NEUTRAL] They're not being specific like it's not broken down into what.
[CUSTOMER][NEUTRAL] Maybe actually owed and so that's where it's difficult for the examiner so I don't think it's necessarily that we need an EOB but truthfully I'm not sure what we would request in its place. Um, let me finish looking because I'm on page 22 now so I'm about done because maybe there was a better breakdown. I'm not sure. It looks like I'm on 319 now.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So 4:39.
[CUSTOMER][NEGATIVE] 20 it it did the same thing like the charges there it says drugs which we know based on the other bills submitted that that is the chemo that we're looking at they have what they allowed but they're not showing that they paid anything they're not showing that the insured owes anything.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And so it's one of those things where it's like yes there is an EOB attached but it's not giving us the information that we need so I don't know that it's that another EOB is needed um.
[CUSTOMER][NEUTRAL] That one's tough because they're they're not it it's so difficult because they're.
[AGENT][NEUTRAL] So
[AGENT][NEGATIVE] What should we do? cause she's like, yeah, cause she's frustrated, which I get cause she's like, I feel like every time I file one, you know, and I, yeah, I need to go back and let her know.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, so let her know that um that it's gonna be reviewed we'll give her a call before the end of the day it may even be within the next hour I'm not sure with what needs to happen because it could be that based on what we have we can go back and be like OK they allowed this amount.
[CUSTOMER][NEUTRAL] Or it may be well they're not showing that they paid anything so if they did we need something showing from your insurance company that they paid towards this specific charge. I'm not sure um because with it being based on actual charges if there are no actual charges.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Then I'm pretty sure there's a remark code out there that says that no actual charges like were incurred but at the same time it looks like it's like that on every single charge but then it shows that they paid like a little over $3400 for this data service but that's strictly for the treatment room so it's it's really confusing, you know, on what's going on here. I, I'm not sure honestly.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. If she's like,
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK. Yeah, I told her we could call her back and she was like, well, nobody ever calls me back. So, um, if she
[CUSTOMER][POSITIVE] I promise I will. What's her number? I will call her personally.
[AGENT][NEUTRAL] Um, her number is [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK, so I'm going to discuss this possibly with another auditor maybe even with the supervisor and just be like this is what was done, but we have an EOB.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The issue is that the EOB doesn't indicate actual charges, so do we have an issue of an incorrect remark code being used or do we have an issue of needing more information and maybe an EOB note needed to be included or something like that? Like I feel like more information is needed in some form. I just am not sure because this this is very rare truthfully for us to see where they pay.
[CUSTOMER][NEUTRAL] Everything they're gonna pay on one line and then they don't pay they allow it they allow money on the other ones but they don't pay anything and they don't put anything to the insured it's a very unusual situation. I don't know that I've seen many if any like this so I am gonna have to kind of reach out and be like hey this is weird. What do we need to do in this situation? And then I will call her back. I don't know when that will be. I don't want to tell her, give me an hour because I don't, I don't know.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, but I will call her today because I'm not in the office tomorrow and I don't want her to go without a phone call so I will call her today.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK. All right. I will go back and let her know. Thank you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Perfect and you can give her my name to say [PII] from claims is calling you back that way when I say hey this is [PII] from APL, she knows, OK.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK. All right. I will, [PII]. Thank you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All right. You're welcome.
[AGENT][NEUTRAL] Bye.
[AGENT][NEUTRAL] Ms. [PII], are you still on the line?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] I apologize for the long hold. um, so I spoke with [PII] in claims, and she's an examiner over there and was going over the claim information.
[AGENT][POSITIVE] She agreed that she saw the EOB and is getting a supervisor to go back over the claim and look at it. She did say that she needs to call you back. She promised that she would call you back and I'm happy to give you my personal number if you'd like and her name is [PII]. I gave her your number and she said she would call you back today. She just needs to do a little research with the supervisor.
[CUSTOMER][NEUTRAL] OK, and what's the number?
[AGENT][NEUTRAL] Um, my callback number, just one second, let me get that for you.
[AGENT][NEUTRAL] Is [PII].
[AGENT][NEUTRAL] [PII] and my first name is [PII] and the last initial to my name is [PII].
[CUSTOMER][NEGATIVE] OK, and can I request for a supervisor to um give me a call back because I need to understand what's the issue, because this is every single time I put in a claim. The last time I put in a claim, the person told me that I wasn't covered. How am I not covered when I'm covered?
[AGENT][POSITIVE] Yeah, absolutely.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] And they had to go back and fix it.
[AGENT][NEUTRAL] Yes, ma'am. I
[CUSTOMER][NEUTRAL] So it's like, every time.
[AGENT][POSITIVE] I explained to [PII] that you were very, very frustrated and that every time you do this, you seem to get a denial, and I was like, you can see she submitted the paperwork. [PII] totally understood where your frustration was coming from, um, and that's why she was getting a supervisor involved. So yeah, I'm happy to let her know that you would like to talk to a supervisor as well.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] All right. So I'm gonna notate the policy, um, and I am here, I don't know what time zone you're on. Um, I'm on Central time, so I'm here until [PII] today and tomorrow.
[AGENT][NEUTRAL] And again [PII] is the one calling back from claims.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Alright well thank you I appreciate it.
[AGENT][POSITIVE] You're welcome, Ms. [PII]. Have a good rest of your day.
[CUSTOMER][NEUTRAL] Mm.