AccountId: 011433970860
ContactId: bbc5d286-feb0-4071-8fdf-9cacdd551f1e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 900099 ms
Total Talk Time (AGENT): 396881 ms
Total Talk Time (CUSTOMER): 338879 ms
Interruptions: 4
Overall Sentiment: AGENT=0.1, CUSTOMER=-1.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/20/bbc5d286-feb0-4071-8fdf-9cacdd551f1e_20250520T17:58_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEGATIVE] Hi, um, I don't know how to use this website for my claims. They keep getting denied and I don't know what's going on, and it doesn't really give me any information.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I can help you with the online service center and your claims, ma'am. Can I please get your name and your callback number just in case the call is disconnected.
[CUSTOMER][NEUTRAL] [PII] and my name's [PII].
[AGENT][NEUTRAL] OK, and then what is your policy number, please?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Good question. There's a sample card, but it doesn't show me. I guess I'm gonna click this little thing.
[AGENT][NEUTRAL] Do you see an inpatient or an outpatient certificate number?
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] On there
[CUSTOMER][NEUTRAL] Um.
[AGENT][NEUTRAL] Or
[CUSTOMER][NEUTRAL] I see a policy number, a claim number on here.
[AGENT][NEUTRAL] OK, what is that?
[AGENT][NEUTRAL] Uh, the policy number, please.
[CUSTOMER][NEUTRAL] Which one, the reference policy?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] 02353000
[AGENT][NEUTRAL] OK, let me look that up real quick.
[CUSTOMER][NEUTRAL] OK, here's the card. um, OK, I got the card now downloaded.
[AGENT][POSITIVE] Oh, good, good.
[AGENT][NEUTRAL] Alright, um, and I've got your policy pulled up, Miss [PII], can you please verify your date of birth for me?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you ma'am, and then what is your address, phone number and email address that we have on the policy for you?
[CUSTOMER][NEUTRAL] [PII]. And the address, I think it's either [PII].
[AGENT][NEUTRAL] Thank you and then one last verification.
[CUSTOMER][NEUTRAL] Or it could be like
[AGENT][NEUTRAL] That's the one that we have is the PO box that you gave me and then Miss [PII], what is your email address?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, I think you guys have [PII], I mean, no, [PII] or it could be [PII], [PII]. I don't know.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] It looks like I have, it looks like I have a work email Keys bank if you can give me that one.
[CUSTOMER][NEUTRAL] Oh, it's NJ at Keys Bank, but I don't use that one.
[AGENT][NEUTRAL] OK. Would you like to?
[CUSTOMER][NEGATIVE] And a lot of stuff goes to spam.
[AGENT][NEUTRAL] Oh my, OK, alright, what would you like for your email address to be?
[CUSTOMER][POSITIVE] Yeah, that would be good.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me update that email address real quick for you, Ms. [PII].
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] And it's [PII], is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right, and.
[CUSTOMER][NEGATIVE] Yeah, like I keep saying processing claims. I gave the insurance information to the doctors and they submit stuff, but I'm like, I don't have a clue what the heck is going on. Like, there's so many claims that aren't getting paid and then some are getting paid. I don't understand it.
[AGENT][NEUTRAL] OK, I can look.
[CUSTOMER][NEGATIVE] There's a ton that have zeros.
[CUSTOMER][NEGATIVE] And these forms don't tell me much, and I'm like, I don't understand. OK, I get it, the co-pays aren't covered, but
[CUSTOMER][NEUTRAL] Isn't anything else? I, I just don't get it.
[AGENT][NEUTRAL] OK alright let me get in there and look at the claims that we have submitted already for you that's already been submitted is that what you're questioning about because I do see one on uh.
[AGENT][NEUTRAL] November I'm sorry, [PII] that was submitted, um, from the Cleveland Clinic that is um in pended status right now. Let's see what it says.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, I'm just confused. I'm like, I don't know what to do.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, ma'am, I understand.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] I show one that was sent on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Have you sent any in yourself? Are you the one that's sending in the claims or is it the facility that's sending in the claims?
[CUSTOMER][NEUTRAL] Insurance company. The insurance company has sent those ones out.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, all right, so looking.
[CUSTOMER][NEGATIVE] And I figured if they sent it out then you guys have all the information but I sent some stuff and it gets denied so I don't, I don't know.
[CUSTOMER][NEUTRAL] I don't know what I'm supposed to send. I figured.
[AGENT][NEUTRAL] It might be because
[AGENT][NEUTRAL] If the insurance company is sending the claims for you, then you wouldn't send them in because then it would duplicate the claim.
[AGENT][NEUTRAL] Does that make sense if they're sending them in for you.
[CUSTOMER][NEUTRAL] Yeah, but I haven't. I'm just waiting for them to.
[CUSTOMER][NEGATIVE] Well, I, I haven't gotten anything to send in like all these ones here with the zeros they've sent those in, but they just keep coming back 0.
[AGENT][NEUTRAL] OK. So I'm looking
[AGENT][NEUTRAL] Yeah the one that was sent on [PII]. It's claim number 3601772.
[AGENT][NEUTRAL] And let's see if what the remark is.
[CUSTOMER][NEUTRAL] OK, I click on that.
[AGENT][NEUTRAL] It says
[AGENT][NEUTRAL] It has like a remark on it that benefits payable under the certificate are limited to those outlined on the schedule of benefits. This is not a covered loss under the plan. Therefore, no amount is payable for this expense, so it's non-covered under your plan.
[AGENT][NEUTRAL] So,
[CUSTOMER][NEUTRAL] But until 1000.
[CUSTOMER][NEUTRAL] $36 but not, it's not covered? Like what is it?
[AGENT][NEUTRAL] So your policy, and this is just to verify your benefits, it's not a guarantee of payment. Your policy helps with deductible, co-pay and co-insurance only.
[AGENT][NEUTRAL] And you have benefits per calendar year of inpatient.
[AGENT][NEUTRAL] Is $1000 per calendar year to help with deductible, co-pay or co-insurance. Your outpatient benefit per calendar day is $250 to help with deductible co-pay or co-insurance. So that might be where the confusion, it doesn't cover anything that the primary doesn't pay. It only helps with deductible co-pay or coinsurance.
[CUSTOMER][NEGATIVE] Then why is the insurance not paying this? I have insurance that tells me I've hit my $1000 deductible.
[CUSTOMER][NEUTRAL] I'm a little confused, like,
[AGENT][NEUTRAL] Now as far as your primary insurance company, I can't help with claims information with them. You'll have to.
[CUSTOMER][NEGATIVE] So I don't understand what you're saying in, in pocket and out pocket, I don't understand what does that mean? $1000? What is, what is considered, I don't know what that's considered.
[AGENT][NEUTRAL] OK, so if, if you go inpatient for 8.
[CUSTOMER][NEUTRAL] I don't know what that means.
[AGENT][NEUTRAL] 15 hours or more, you have to stay in the hospital for 18 hours or more. This policy helps with your deductible, co-pay, and co-insurance from your primary insurance only.
[AGENT][NEUTRAL] That's what that meant. Um, so you, that's why we always have to have the explanation of benefits from your primary insurance to show what they paid before we can pay because it's based on what they pay.
[CUSTOMER][NEGATIVE] I don't get it. Some things got paid that like I submitted in and like, even like when I had the mammogram, I got paid. That was 150. I don't understand it. It doesn't make sense cause I didn't stay in the hospital.
[AGENT][NEUTRAL] Right, and your mammogram was outpatient procedure, is that correct?
[AGENT][NEUTRAL] You didn't, you didn't stay in the hospital.
[CUSTOMER][NEUTRAL] I don't know it was a network.
[AGENT][NEUTRAL] Right, so your mammogram.
[CUSTOMER][NEUTRAL] No, I didn't stay in the hospital.
[AGENT][NEUTRAL] Right, so when you have outpatient services that you don't have to stay in the hospital for, this policy pays $250 a day.
[AGENT][NEUTRAL] Towards deductible copay or co-insurance, so when you had your mammogram, you probably had to pay a deductible or a co-pay or a co-insurance and that's when this policy kicked in and picked that up for you.
[CUSTOMER][NEGATIVE] But some of the other one, I don't get it like.
[CUSTOMER][NEUTRAL] I don't know. So, uh, cause there's a lot of them.
[AGENT][NEUTRAL] Do you have um
[AGENT][NEUTRAL] So you're, you said you were on the online service center, is that correct?
[CUSTOMER][NEGATIVE] Yeah, I'm on here now, but it doesn't, I don't understand it and it doesn't tell me. Like I keep getting some claims submitted for everything. Like I've had a couple of surgeries and procedures done and none of those have gotten paid. The anesthesiologist bill I sent in was $278 or something, and that one didn't get paid. Like I don't understand that they, how are these things get paid?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] It's based on deductible copay.
[CUSTOMER][NEGATIVE] It doesn't make any sense to me and this.
[AGENT][NEUTRAL] It's all based on deductible copay.
[CUSTOMER][NEUTRAL] Oh what is this like this one, the one that says it's still waiting for stuff.
[AGENT][NEUTRAL] Probably got information that needs the um documents or some kind of claims information that needs to be sent in still sometimes when not all the information is sent in we have to send out letters.
[AGENT][NEUTRAL] For requesting the information that we need so then it'll go into waiting status until we get the stuff, the all the paperwork that we need to finish your claim.
[CUSTOMER][NEGATIVE] Yeah, I'm just trying to see because I don't understand like this one here is 0 and that was.
[CUSTOMER][NEUTRAL] Uh, for one, the dating is a little off.
[CUSTOMER][NEUTRAL] Why is the dates are like the dates coverage are off? Why is that? Why are they not in order?
[AGENT][NEUTRAL] It depends on when the claim was sent in. It goes by it goes by the date this claim was actually sent in rather than the date of service. So if, if you went to the doctor, let's say [PII], and it didn't get in sent in until the [PII], but a claim that came in from April before the [PII] did, then we, it, it's based on how we received them rather than the date of service.
[CUSTOMER][NEUTRAL] I'm just trying to
[CUSTOMER][NEUTRAL] Yeah, cause I just opened up this one here and it's 0 and it's Cleveland Clinic and it says office visit. Well, that's the one the doctor sent in. I don't think I sent that in, but that's all the way.
[AGENT][NEUTRAL] What is that claim number?
[CUSTOMER][NEGATIVE] I don't even know. It was billed $78.
[CUSTOMER][NEUTRAL] Um, it's 359-3702.
[AGENT][NEUTRAL] OK, let me look at that one.
[CUSTOMER][NEUTRAL] This one's from [PII].
[CUSTOMER][NEUTRAL] The amount billed $78.
[CUSTOMER][NEUTRAL] It says office is it not covered. Well, what is, what is that? I don't know like.
[AGENT][NEUTRAL] So, under your policy, your policy does
[CUSTOMER][NEUTRAL] For one on-off visit, I don't.
[CUSTOMER][NEGATIVE] I don't pay a 6, I don't pay $78 for an office visit, so that's not even a charge what they pay. My insurance pays in a $60 out of pocket.
[AGENT][NEUTRAL] And it
[AGENT][NEUTRAL] OK, so
[CUSTOMER][NEUTRAL] So why is it $78? Where, where are the details that go with this?
[AGENT][NEUTRAL] That comes from the provider's office that you went to uh from an itemized statement.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] Well I don't see any of that information. It doesn't show me anything else. It just says.
[CUSTOMER][NEGATIVE] Office visits are not covered. Well, I don't pay $78 so.
[AGENT][NEUTRAL] Right. Of visits under your.
[AGENT][NEUTRAL] Yeah and we don't have anything to do with the charge amounts that are sent in that's sent in from the provider.
[AGENT][NEUTRAL] If you are in the online.
[CUSTOMER][NEUTRAL] Yeah, because that's just an odd number because.
[AGENT][NEUTRAL] If you're in the online service center.
[CUSTOMER][NEUTRAL] Yeah, I'm here but it doesn't show me what else is uploaded.
[AGENT][NEUTRAL] Can you go to your policy certificate so that you can read your policy certificate and understand your benefits better it breaks.
[AGENT][NEUTRAL] Uh for you on the schedule of benefits, what is
[CUSTOMER][NEUTRAL] Yeah, but I'm trying to figure out what all these charges are because that's.
[CUSTOMER][NEGATIVE] $78. I didn't submit that bill. I don't know what $78 is cause my insurance is $60. So why is that extra money added in? What goes with that? Who sent that in to
[CUSTOMER][NEUTRAL] Say that it's an office visit? What else goes with that?
[CUSTOMER][NEGATIVE] I just don't understand because there's no other information that's provided with these things, these claims that have been submitted.
[CUSTOMER][NEUTRAL] So when I look back on 331, but how my sister know what else want with that? It doesn't.
[CUSTOMER][NEGATIVE] It doesn't show me. Like when I upload the bills, I can see everything I uploaded with it.
[CUSTOMER][NEGATIVE] And I don't understand this weird payout of $16.65. I don't understand that one. What did where did that weird amount come from?
[CUSTOMER][NEUTRAL] Do you see what I mean?
[CUSTOMER][NEUTRAL] And like there's no remarks, they just paid $16.65 on this claim on 42.
[CUSTOMER][NEGATIVE] But what is the $16 for? I don't understand.
[CUSTOMER][NEUTRAL] Hello? Are you still there?
[CUSTOMER][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] Can you hear me?