AccountId: 011433970860
ContactId: bab0f418-a9f7-44c6-9380-b27b2119e77d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1543000 ms
Total Talk Time (AGENT): 582461 ms
Total Talk Time (CUSTOMER): 574147 ms
Interruptions: 4
Overall Sentiment: AGENT=0, CUSTOMER=-0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/15/bab0f418-a9f7-44c6-9380-b27b2119e77d_20250515T12:25_UTC.wav
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[CUSTOMER][NEGATIVE] I didn't get the money. They paid me. I don't get it.
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], good morning. How are you? My name is [PII] and I'm calling because I have the um the the the the gap with you guys, and I was actually in the hospital on [PII], and I submitted everything that I possibly can that I got from United Healthcare to you guys since [PII], like literally since [PII], I think I started submitting everything.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] And I keep on getting information that you guys need more information and more information. I really don't understand what else you guys need. I send you everything that I have from United Healthcare. You guys are asking now. I just received a letter yesterday saying that you guys are asking. We are unable to use your payment receipt process your claim, please submit a full item bill with diagnostic and procedure. I mean, I had surgery at Memorial Hospital and uh I had a um.
[CUSTOMER][NEUTRAL] Um, an abscess in my stomach.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So, I mean, I, I don't know how much more you guys need from me, but I kinda wanna get this resolved because I do need the money. I was in the hospital for 2 weeks.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Yeah, absolutely, [PII]. Let's take a look. I'm sorry for any frustration. What is your policy number?
[CUSTOMER][NEUTRAL] Oh yeah.
[CUSTOMER][NEUTRAL] Um, my policy number is 02111201. I have my claim number if that helps even more.
[AGENT][POSITIVE] Yeah, absolutely. You can give me that. Go ahead.
[CUSTOMER][NEUTRAL] 3597498
[CUSTOMER][NEUTRAL] Cause I was admitted twice. So the first paper that I sent you guys, it was when I was admitted [PII] and I left [PII]. Then I went back and uh I went to urgent care. And then from the urgent care, they transferred me again to [PII], and that was like April, I think.
[CUSTOMER][NEUTRAL] I don't know. I don't remember the date [PII] until the [PII], I was in the hospital.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] They pay for the and then I already got a payment from you guys from the ambulance $388 and I already received that, but I don't understand the status on everything else.
[AGENT][NEUTRAL] OK. So first thing I need to do, [PII], is I just need to verify your date of birth and address, please.
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So on this one that you gave me the first claim that ends in 498.
[AGENT][NEGATIVE] Part of the denials.
[CUSTOMER][NEUTRAL] Oh, so everything, everything, everything that I sent is different claim numbers. Can I put you on the speaker because I'm here with my friend that's helping me with this. Can I put you on speaker if you don't mind?
[AGENT][NEUTRAL] Mhm, mhm.
[CUSTOMER][NEUTRAL] Hold on.
[CUSTOMER][NEUTRAL] I I
[AGENT][NEUTRAL] So, I mean, we can go back to the very like first claim if you want to, um, but yeah, I mean, everything that
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I submitted is a different, a different claim number.
[CUSTOMER][NEUTRAL] Oh, I didn't know that. So every time we submit a paperwork it's a different um referral number.
[AGENT][NEUTRAL] Yeah, and I mean if you're, if you're just uploading like additional documentation, then um it'll just attach to to that claim, uh.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] So the first one that you gave, the 7498, the one that ends in that.
[AGENT][NEUTRAL] So there were 2 different things submitted on it, it looks like a durable medical equipment was one of them.
[CUSTOMER][NEUTRAL] Mhm, mhm.
[AGENT][NEGATIVE] So, that was a denial. It looks like medical equipment's not covered under the policy.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Now, the second one, let's see what that is showing for.
[AGENT][NEUTRAL] Was physical therapy on [PII].
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] I don't, I didn't do physical therapy.
[CUSTOMER][NEUTRAL] I mean, I'm going to a womb specialist, but there's no therapy there.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Perfect that.
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] So that's what they're talking about here. Mhm. And what's the one that's not physical therapy that's uh that's the machine, the machine, yeah, I wound specialist, yeah, but they said that they, the cat doesn't cover that morning.
[AGENT][NEUTRAL] So, yeah, it looks like this was probably
[CUSTOMER][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] Um, like you said, wound care.
[AGENT][NEUTRAL] Talking about, so it's a letter that you took a picture of that you submitted to us. This is therapy start date for [PII] from 3M Medical Solutions.
[CUSTOMER][NEUTRAL] Mhm mhm.
[CUSTOMER][NEUTRAL] You just.
[CUSTOMER][NEUTRAL] Uh-huh, uh-huh, yeah.
[AGENT][NEUTRAL] So is that, is that wound care?
[CUSTOMER][NEGATIVE] Yeah, that's the I'm, I'm using a machine and I'm stuck with it. I'm like I'm using it still.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so we're on this particular claim, were you just trying to get the reimbursement for the machine?
[CUSTOMER][NEUTRAL] If I could, but you're saying that it's really important.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh-huh. It's attached to, yeah, it's attached to me.
[CUSTOMER][NEUTRAL] It's called the wom bag.
[AGENT][NEUTRAL] So,
[AGENT][NEUTRAL] The other denial code on this is that we can't use receipts, but it wasn't really a receipt, it was just a copy of the letter.
[AGENT][NEUTRAL] So,
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Medical equipment isn't a covered expense under the secondary.
[AGENT][NEUTRAL] Um, if you have any sort of
[AGENT][NEUTRAL] reimbursement that you need from the actual um treatment, then we need an itemized bill.
[AGENT][NEUTRAL] So an itemized bill is something that you would contact the provider for because it has procedure codes on it.
[CUSTOMER][NEUTRAL] OK, what about?
[AGENT][NEGATIVE] It's not like a bill that you get in the mail. It would be something that they could provide you with the codes on it for what they're treating.
[CUSTOMER][NEUTRAL] When you get that hospital? And where do I get that from the hospital? The wound specialist?
[AGENT][NEUTRAL] So, if we're speaking [PII]rectly to the wound care, it would be whoever is providing that wound care to you.
[CUSTOMER][NEUTRAL] What crack, which is memorial Pendle.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] And a doctor or a provider?
[AGENT][NEUTRAL] should understand what you mean as far as an itemized bill with diagnosis and procedure codes. Procedure codes are codes for what is being given or done to you. A diagnosis code is the code of what, what the result was, what you were diagnosed with.
[CUSTOMER][NEUTRAL] I see.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] And this
[CUSTOMER][NEUTRAL] OK, but I don't know if they will or not. OK, so let's just forget about that case. What about the first case that I ever opened when I was admitted to the hospital?
[AGENT][NEUTRAL] Let me get back to the very first claim and see what that says.
[CUSTOMER][NEUTRAL] Oh,
[CUSTOMER][NEUTRAL] The last file or the that has explanation of benefits with the last file we put is explanation of benefits payment from uh insurance company from the insurance company. What day was that that we submit that [PII] [PII].
[CUSTOMER][NEUTRAL] Uh, let me see, they received me first.
[CUSTOMER][NEUTRAL] Let me first.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Oh, you get paid for that. I'm, I'm.
[CUSTOMER][NEUTRAL] What about
[CUSTOMER][NEUTRAL] I mean, cause I had surgery, I had, I don't know.
[CUSTOMER][NEUTRAL] Cause I thought the gap pays when you were in the hospital more than 2 days.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] I have yeah.
[AGENT][NEUTRAL] OK, so the very first claim.
[AGENT][NEUTRAL] Is
[AGENT][NEUTRAL] The stay 41 to 43 and then 46 to 412.
[AGENT][NEUTRAL] That
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Claim needs.
[AGENT][NEUTRAL] The explanation of benefits from your primary for those dates.
[AGENT][NEUTRAL] Because we're your sex.
[CUSTOMER][NEUTRAL] We put it on, we locked.
[AGENT][NEUTRAL] OK, let me check and see.
[CUSTOMER][NEUTRAL] But we, we submitted it, OK, OK, OK, we submitted it, but what we've been doing is when we load it, I guess that we're creating a new policy, uh, a new case number.
[AGENT][NEUTRAL] Let me check.
[CUSTOMER][NEUTRAL] That's what I think the problem is.
[CUSTOMER][NEGATIVE] It's my first time using this and doing this, so I really lost.
[AGENT][NEUTRAL] Yeah, if you ever, if you can get
[AGENT][NEUTRAL] a doctor or a hospital to do it for you. It's generally
[CUSTOMER][NEUTRAL] Diagnosis code.
[AGENT][POSITIVE] Much easier.
[CUSTOMER][NEGATIVE] Yeah, but it's unfortunately it's impossible to do that. That's the problem.
[CUSTOMER][NEGATIVE] It's it was a mission to be there and get answers from them and I didn't to do this.
[CUSTOMER][NEUTRAL] Because I went online to my UnitedHealthcare and I printed the benefits and I scanned it on you guys' profile.
[CUSTOMER][NEUTRAL] And uploaded the files, but the thing is that when we go in there and we provide we do this, it's giving a new policy number you see all those claim numbers is creating new claim numbers so they it needs to be attached to the first one and it's not doing that. No, that's true.
[CUSTOMER][NEUTRAL] Yeah, but
[AGENT][NEUTRAL] So I'm looking at the upload on [PII].
[AGENT][NEUTRAL] There were 2 of them. Let me check the 4251, because so far,
[AGENT][NEUTRAL] What we need from the explanation of benefits is we we need to be able to see what your primary insurance paid towards deductible, co-pay, co-insurance, all that stuff, and I haven't found that yet, so.
[CUSTOMER][NEUTRAL] So it's something that I need to call. I mean, this is such a mission, to be honest. So I have to call United Healthcare and ask them to email me or print out for me a beneficial by.
[AGENT][NEUTRAL] Well, I mean, if you have a United Healthcare app, your explanation of benefits, yeah, should be on there for the dates of service.
[CUSTOMER][NEUTRAL] I do.
[CUSTOMER][NEUTRAL] Which we didn't, that's what we, what we, that's what we emailed you guys, we got those, yeah.
[CUSTOMER][NEUTRAL] So there's 2 of them and we uploaded them. Yeah.
[AGENT][NEGATIVE] No, I see the first one. It's 13 pages, and I'm looking at each one of the pages. I see where like it says medications that were given to you. Um, there are a bunch, I don't know what happened on the upload cause there's a bunch of blank pages in between.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Like there's medications that were prescribed to you, but like I, I haven't seen anything yet that shows
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] United Healthcare explanation of benefits, data service amount charged amount applied towards deductible, uh co-pay. I don't see any of that so far. Let me check.
[CUSTOMER][NEUTRAL] Because I am on UnitedHealthcare's website right now.
[AGENT][NEUTRAL] Oh here's one. OK, what's this one?
[AGENT][NEUTRAL] Explanation of benefits.
[AGENT][NEUTRAL] For the emergency room on [PII].
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] All right, and then I see another explanation of benefits from that you uploaded on.
[AGENT][NEUTRAL] 512.
[AGENT][NEUTRAL] That they did move with your claim that ended up paying.
[AGENT][NEUTRAL] It looks like they linked it to that because it looks like it went with that.
[AGENT][NEUTRAL] That was.
[CUSTOMER][NEUTRAL] But what we see is from ambulatory. Yeah, I was you guys sent me was the ambulance money that um that I guess.
[AGENT][NEUTRAL] 428.
[CUSTOMER][NEUTRAL] I try to see if I can use the road when I go.
[CUSTOMER][NEUTRAL] Uh, towards the next month.
[AGENT][NEUTRAL] So the only explanation of benefits that I see on here was for the emergency services 331343.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Just.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I'll see if that works and then.
[AGENT][NEUTRAL] I've scrolled through every single upload and every single page.
[AGENT][NEUTRAL] And those are the two that I see on my side.
[CUSTOMER][NEUTRAL] need to plug I have gone out of the car to lugging in the all the.
[AGENT][NEUTRAL] So, the only thing that needs to be uploaded that I see is the inpatient stay.
[CUSTOMER][NEUTRAL] The what?
[AGENT][NEUTRAL] Explanation of benefits.
[AGENT][NEUTRAL] From 41 to 43.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] And then 46 to 412.
[CUSTOMER][NEUTRAL] Hold on, let me write this down.
[CUSTOMER][NEUTRAL] 4143. And what? 46?
[CUSTOMER][NEUTRAL] 46 to 412.
[AGENT][NEUTRAL] Right, so it's 41 to 43 and then 46 to 412.
[AGENT][NEUTRAL] So explanation of benefits for those dates.
[AGENT][NEUTRAL] And the only other thing that I see that's being requested.
[AGENT][NEUTRAL] Is
[AGENT][NEGATIVE] Either an itemized hospital bill.
[AGENT][NEUTRAL] Or you can ask the hospital for an admin discharge summary.
[CUSTOMER][NEUTRAL] She [PII]
[CUSTOMER][NEUTRAL] What is it?
[CUSTOMER][NEUTRAL] Admin discharge.
[AGENT][NEUTRAL] Uh.
[AGENT][NEUTRAL] Right, an admin discharge summary.
[CUSTOMER][NEUTRAL] Admin discharge summary.
[AGENT][NEUTRAL] Right, because that's gonna have your diagnosis code on it. And so if you ask for that, that may be the easiest because it's also gonna have diagnosis code. So you could do explanation of benefits if in that on one upload.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] And then if you wanted you can write the claim number it's associated with on it even though one of the uploads you did they linked it back to that claim, but if it makes you feel better you can write the claim number on the information.
[CUSTOMER][NEUTRAL] And what is the um claim number?
[AGENT][NEUTRAL] 359.
[AGENT][NEUTRAL] 0514.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And that was the original claim that was started, the very first one.
[CUSTOMER][NEUTRAL] So, OK, let me just ask, uh, if she do go to the hospital, she uh she can ask for the admin discharge summary, is that good enough? Because you like you said, there's gonna be diagnosis code in there for every procedure that's done in the hospital, correct?
[AGENT][NEUTRAL] Well,
[AGENT][NEUTRAL] We, yeah, we do, we do still need the explanation of benefits that is still needed also.
[CUSTOMER][NEUTRAL] And that's from the insurance or hospital also?
[AGENT][NEUTRAL] That's from the primary insurance. Because we're secondary, right, because we're secondary insurance, we only pay if primary pays. So that's why we need to be able to see what they pay towards services, and then, you know, we reimburse accordingly, because if the primary insurance didn't pay, then we wouldn't pay.
[CUSTOMER][NEUTRAL] Primary insurance?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] New addition let's see.
[AGENT][NEUTRAL] So, to, from what I can see, that's the only thing um that is missing it's just those explanation of benefits and then the diagnosis code with the itemized receipt or that hospital admin discharge summary.
[CUSTOMER][POSITIVE] Good morning.
[CUSTOMER][NEGATIVE] No, let me ask you, she, um, when she went to the hospital, she's been seeing radiologist also, and the, uh, insurance paid for that for 894, but total she owe is $11694. You guys don't cover that.
[CUSTOMER][NEUTRAL] That was on [PII].
[AGENT][NEUTRAL] Was a claim submitted for it?
[CUSTOMER][NEUTRAL] Yes, because, uh, they already paid the, they already paid the United Healthcare, but she's still owe 116.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][POSITIVE] Uh, you mean if we submitted that, do you want me to, I, I mean, I'll be, we'll be happy to submit that.
[CUSTOMER][NEGATIVE] And I have another question. There is some, uh, procedure that that has been done in the hospital, but, uh, it's saying that here that it's out of the network, so the claim was denied. So now she had to pay that $432 for the uh procedure that's done in the hospital, but it was denied.
[AGENT][NEUTRAL] What was the claim number for the?
[CUSTOMER][NEUTRAL] So do you guys would cover that?
[AGENT][NEUTRAL] I would need claim numbers for these to be able to speak to the denial reason.
[CUSTOMER][NEUTRAL] No, we need.
[CUSTOMER][NEUTRAL] OK, so let me just uh upload the explanation of benefits so we have more understanding what we're talking about. So over here.
[CUSTOMER][NEUTRAL] Claim processing code is CU. I don't know what's that.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Provider pay, but we didn't submit them to APL.
[CUSTOMER][NEUTRAL] I did, um.
[CUSTOMER][NEUTRAL] OK, we can submit it.
[AGENT][NEUTRAL] Yeah, I mean, just keep in mind that anytime that you're doing a claim on this insurance, you're going to need the itemized bill with the procedure and diagnosis code, and you're also always going to need the explanation of benefits from the primary insurance.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, thank you. So, OK, we can just we can submit it again. So if I upload this and then, uh, print and and uh scan and download to, I think we did send that with us.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] We did. That's this one. When did you upload that? The other day? What day is that so we could give you the claim number? OK, [PII]. Let's.
[CUSTOMER][NEUTRAL] 19, probably.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Maybe this one.
[CUSTOMER][NEUTRAL] Yeah, OK, uh, we did submit this what we're talking about, yeah, with the explanation of benefits. OK, let's give her the claim number we submitted on.
[CUSTOMER][NEUTRAL] OK, so I just send the one that works.
[CUSTOMER][NEUTRAL] [PII], the claim number is 211201.
[AGENT][NEUTRAL] OK, that one's still in progress.
[CUSTOMER][NEUTRAL] that's your policy number.
[CUSTOMER][NEUTRAL] It's still in progress, OK, OK, so that has it.
[AGENT][NEUTRAL] Yeah, the one on the [PII] I I show reported, but it, it's not, there's no decision made on it or anything as of yet. It's still showing in progress.
[CUSTOMER][NEUTRAL] Oh, still in progress, so you guys still reviewing it.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Right, exactly.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All right, thank you so much for your time.
[AGENT][NEUTRAL] Yeah, you're welcome. If you have any other questions, please call back, OK?
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Mhm.