AccountId: 011433970860
ContactId: bc88e812-dc67-42c3-9df4-6d4c13a61664
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 2445739 ms
Total Talk Time (AGENT): 701531 ms
Total Talk Time (CUSTOMER): 800969 ms
Interruptions: 21
Overall Sentiment: AGENT=0.1, CUSTOMER=-0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/28/bc88e812-dc67-42c3-9df4-6d4c13a61664_20250528T15:02_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi Ms. [PII], this is [PII] in the care team. I've got, hi, I've got Mr. [PII] on the phone.
[AGENT][NEUTRAL] Hi.
[CUSTOMER][NEUTRAL] Uh, his policy number is 1986454.
[CUSTOMER][NEUTRAL] I have verified him. His callback number is actually the number he's calling from the [PII]. He is.
[AGENT][NEUTRAL] OK, what is he calling in regards to?
[CUSTOMER][NEUTRAL] He called because he wanted to know if we received the claims that he sent in and I told him yes and one of them was sent on [PII] and it had a remarks so I read the remarks and he has further questions.
[AGENT][NEUTRAL] On that particular claim, the 35999598?
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Yes, the 359-959-8.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] You can send them to me.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Alright thanks [PII] bye bye.
[AGENT][POSITIVE] Thank you. You're welcome.
[AGENT][NEUTRAL] Claims department, this is [PII].
[CUSTOMER][NEUTRAL] Yes, how you doing? Uh, I don't know if you got the information. I got transferred. Uh, do you have my information?
[AGENT][NEUTRAL] Fine, how are you?
[AGENT][NEUTRAL] Yes, yes, she did provide me with that information, Mr. [PII], you were calling in regards to the claim that was recently processed on.
[AGENT][NEUTRAL] Recently processed on [PII], you have some questions about that claim?
[CUSTOMER][NEUTRAL] OK, yes, OK, I don't know what's going on, but you, uh.
[CUSTOMER][NEUTRAL] There was a kidney stone surgery that took place on May, actually on [PII].
[CUSTOMER][NEUTRAL] [PII]. OK.
[CUSTOMER][NEUTRAL] I think it's at the same time, is that correct?
[AGENT][NEUTRAL] OK, on this claim, it looks like there, yes, there was uh
[CUSTOMER][NEUTRAL] Maybe that's the problem with your forms are really like not uh oh here it is, it says.
[AGENT][NEUTRAL] Yes, it looks like there was a data service for 426 of 22.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEGATIVE] OK, now she's saying that that claim was reviewed and not and not paid for what and not paid for what reasons.
[AGENT][NEUTRAL] We requested the explanation of benefits from your primary insurance carrier.
[CUSTOMER][NEUTRAL] Which was sent.
[AGENT][NEUTRAL] OK, on this particular claim, it was sent?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, let me take a look at the documents.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, on this mail received on this claim process, I don't see that we received the explanation of benefits from your primary insurance carrier. I see we have a new mail. Let me take a look to see.
[CUSTOMER][NEUTRAL] Yeah, wait, wait, wait.
[CUSTOMER][NEUTRAL] It's um.
[CUSTOMER][NEUTRAL] Humana.
[AGENT][NEGATIVE] We did not receive a Humana explanation of benefits on this meal received on [PII].
[CUSTOMER][POSITIVE] Oh my gosh, I like uh so much paper and that's so.
[CUSTOMER][NEGATIVE] Excuse me to tell you, but you're really outdated. We have to be having to send fax. It's like dozens of sheets of paper when you could just do it electronically. It's kind of ridiculous. And then everything notification by mail, you have to make calls. It just spend a lot of time. That's the reason of delay making these claims, but look.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] What did you get the one for?
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] 22
[CUSTOMER][NEUTRAL] [PII]. That's the same company, Humana, that has an EOB on it also. I think they both went together with the EOB at the end.
[AGENT][NEUTRAL] And then you sail for [PII].
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] I was in the hospital [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Cardiovascular surgery, we ran up a bill of about 200,000. I think you'll, you'll be able to process that one pretty fast because there's no question about it.
[AGENT][NEUTRAL] OK, so was that, was that [PII] or [PII]?
[AGENT][NEUTRAL] Or is the actual data service, OK.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII] data service [PII], I was in the hospital intensive care.
[CUSTOMER][NEUTRAL] And that particular one I know has an EOP. I think that I resent the two together.
[CUSTOMER][NEUTRAL] Maybe that's what I did.
[AGENT][NEUTRAL] OK, so that's for data service of [PII].
[CUSTOMER][NEUTRAL] I thought I had red done both of them.
[CUSTOMER][NEUTRAL] Yes, you have the EOB on that one?
[AGENT][NEUTRAL] Let me take a look to see if we have that claim.
[AGENT][NEUTRAL] OK, I'm not showing claim process for December data service. Let me take a look at the new mail received to see if it's in those documents.
[AGENT][NEUTRAL] OK, Mr. [PII], I'm gonna put you on a brief hold so I can look through the most recent documents that the new mail received to see if I can see that data service, but on previous claims, I don't show anything for a December data service for 22.
[CUSTOMER][NEUTRAL] What claims what claims do you have for me?
[AGENT][NEUTRAL] Um, claims that have been processed goes back to.
[AGENT][NEUTRAL] Let me take a look here.
[CUSTOMER][NEUTRAL] Recently in the last two months.
[AGENT][NEUTRAL] OK, recently it's a claim that was processed on [PII]. It looks like those dates of services are from.
[AGENT][NEUTRAL] Dates go back from [PII], I mean from [PII] up until.
[CUSTOMER][NEUTRAL] OK, but you see, here's the thing.
[CUSTOMER][NEUTRAL] When you what confuses everything is that you ask for an EOB and the EOB is gonna show everything or maybe something doesn't apply.
[CUSTOMER][NEUTRAL] Because it's gonna show everything and then in one little box, most insurance companies are doing that.
[CUSTOMER][NEUTRAL] What year my policy was, what my out of pocket was what my maximum.
[CUSTOMER][NEUTRAL] Uh, what deductible was that kind of thing. That's an explanation of benefits. So if you take 11 office visit, the person I was talking about before, he says we don't cover office visits, of course not.
[CUSTOMER][NEUTRAL] So there's a gap policy to cover surgery, stuff like that.
[CUSTOMER][NEUTRAL] So then that's on that particular one that you're saying it was an office visit, took the EOB and they marked the date where I had the surgery.
[CUSTOMER][NEUTRAL] With an X or whatever I did I don't know.
[CUSTOMER][NEGATIVE] That's why even your form it's like it's nothing. It doesn't even have a place to put where what the data service was so you can go back to it.
[AGENT][NEUTRAL] So on that claim.
[CUSTOMER][NEUTRAL] But anyway, on that particular one.
[AGENT][NEUTRAL] There was no EOB received that shows what was applied towards your deductible co-pay coinsurance for the hospital.
[CUSTOMER][NEGATIVE] OK, I, that I resent everything. I resent the three claims and then there's and then two of them have the same EOB because it's the same company, OK, for [PII], it's Humana. There was an outpatient.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So I'll take a look at those documents.
[CUSTOMER][NEUTRAL] [PII], Humana. Then the [PII] I just told you about [PII] Humana.
[CUSTOMER][NEUTRAL] Then in the, in [PII].
[CUSTOMER][NEUTRAL] There was a hip surgery, memorial.
[CUSTOMER][NEUTRAL] Then you that was the one that was processed first and then you said, oh, there's an address missing on the form. And so the form went back with the billing statement and the EOB and um still at square one. I don't know how it is complicated.
[AGENT][NEUTRAL] OK, and that was for what data service was that one in regards to?
[CUSTOMER][NEUTRAL] So you said that you, you, you have to go look at your pile of faxes you, you need to go look at your pile of faxes to see if I got the EOB. Could you check that? I'll wait.
[AGENT][NEUTRAL] OK, give me one moment, I'm gonna put you on a brief hold while I look through the documents.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Thanks for holding, Mr. [PII]. I do show you did receive the billing in for the [PII], dates of service.
[CUSTOMER][NEUTRAL] And you got the EOB, right?
[AGENT][NEUTRAL] I show we got the EOB on one of the charges. It looks like for some diagnostic. I don't show that we have the EOB for the hospital.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] But, but that's what it is that they, they don't show.
[CUSTOMER][NEGATIVE] They don't show
[CUSTOMER][NEUTRAL] When you ask for EOB.
[CUSTOMER][NEUTRAL] And EOB is the uh you see all the charges uh I don't know what it was $200,000 or whatever it was, let's see.
[AGENT][NEUTRAL] On the hospital bill?
[CUSTOMER][NEUTRAL] For the surgery on the [PII], uh, because I was in the hospital a week, so wait a minute, so when you, when you ask for an EOB from these companies, that's what they give you explanation of benefits disregard with that little bill in the front, but the explanation of benefits is what it is that you have a certain amount of deductible, all that, but I went through that whole thing and uh max amount of pocket because 7 days cardiovascular surgery and everything.
[CUSTOMER][NEUTRAL] Added up to I think $200,000 so there's no question about that one and the other one either and so that EOB.
[CUSTOMER][NEUTRAL] From Humana
[CUSTOMER][NEUTRAL] It's the same thing, the same EOB because the same year for the [PII], and I was just looking through that bill, that ended up being 62,000 for an outpatient kidney stone surgery.
[AGENT][NEUTRAL] So for the
[CUSTOMER][NEUTRAL] So I maxed out.
[AGENT][NEUTRAL] The only EOB that I see for the [PII].
[CUSTOMER][NEUTRAL] [PII] date.
[AGENT][NEUTRAL] I sure charge for North.
[CUSTOMER][NEUTRAL] The EOB for [PII].
[CUSTOMER][NEUTRAL] It is the same it's the same EOB explanation of benefit. Are you looking for what the what the insurance pay or explanation of benefits? Explanation of benefits shows you that you were covered and that you and what your insurance covered you for.
[AGENT][NEUTRAL] The, the explanation of benefits for the particular charge amount on the claims that you're filing for. So for example, for the hospital bill, it looks like your total bill amount for the hospital looks like your, the total bill charge was for $130,985.18. I do not show that we have the explanation of benefits for Humana for this charge for the hospital facility.
[CUSTOMER][NEUTRAL] That's it.
[AGENT][NEUTRAL] The only explanation of benefits that we do have from Humana, it looks like for you had some radiology done on that same day and it looks like the total charge amount was $36 so we have that explanation of benefits.
[CUSTOMER][NEUTRAL] OK, but look, man, that's the only insurance I that I had.
[CUSTOMER][NEUTRAL] What you want to see what they paid, they paid everything.
[CUSTOMER][NEUTRAL] And and then I hit my maximum deductible maximum out of pocket, which is what your gap company covers so that when I hit my maximum you cover.
[AGENT][NEUTRAL] We pick up in regards to your out of pocket up to your max benefit allowed under the policy. We do not have the excellimination of benefits for this hospital charge from the documents that you submitted into us for the [PII] to [PII].
[CUSTOMER][NEUTRAL] So what, what is it that you want from them?
[CUSTOMER][POSITIVE] Oh my gosh, wait a minute. So you're, you make it so complicated for people to, to collect us from that company, from your company. It's amazing how, how good you are at that.
[CUSTOMER][NEUTRAL] OK, expiration of benefits, and I've done it with other insurance companies, they, you just want to see what the explanation of benefits is and that's what it is, what your maximum amount of pocket. I actually went way over that.
[AGENT][NEUTRAL] It will be for each, each service. So one for the hospital facility will need that explanation of benefits. I don't show that we have that in the documents that you submitted to us.
[CUSTOMER][NEUTRAL] In other words, they should
[CUSTOMER][NEUTRAL] OK, let's go over this again.
[CUSTOMER][NEUTRAL] You're gonna, you want an explanation of benefits for that particular date?
[AGENT][NEUTRAL] For that facility bill for the hospital. So from [PII], we will, we need the explanation of benefits for that bill amount of $130,000. That explanation benefits is not listed in the documents that you submitted to us.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So you're gonna need that for the [PII] also.
[AGENT][NEUTRAL] Correct. We still need the [PII] for the hospital facility charge, the EOB.
[CUSTOMER][NEUTRAL] And then let's go oh OK.
[CUSTOMER][NEGATIVE] You're gonna make it really complicated for me, but I'll, I'll go ahead and do it and then once you and tell me now what is your understanding about your damn insurance company? OK, what are you gonna pay me?
[AGENT][NEUTRAL] We're secondary, so we pick up in regards.
[CUSTOMER][NEUTRAL] If you, when you verify that they paid $130,000 what do you, what, let me finish talking. What are you gonna pay?
[AGENT][NEUTRAL] So for confinement, the policy covers the benefit up to 2000 max per calendar year, and for outpatient, it covers up to 2000 max per calendar year and your outpatient benefit. And I just must advise that this is just a verification of coverage. It does not guarantee payment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so what are you gonna look at when you get your EOB?
[CUSTOMER][NEUTRAL] Right, what, what it, what are you gonna be looking at when you get my EOB with $130,000? What are you gonna say? OK, $130,000 that should, that what you will pay.
[AGENT][NEUTRAL] We look at
[AGENT][NEUTRAL] We look, we look at your deductible copay coinsurance applied to that particular date of service for that charge amount, and we pay up to that max benefit allowed under your policy. We look at, we look at the deductible, your out of pocket, your deductible copay co insurance amount applied towards that particular data service and the bill amount on the claims that you submitted up to the allowed amount under the policy for inpatient or outpatient.
[CUSTOMER][NEUTRAL] You do what? Sorry, repeat. You, you will do what?
[CUSTOMER][NEGATIVE] I, I still don't understand what you're saying.
[CUSTOMER][NEUTRAL] What so
[CUSTOMER][NEUTRAL] If, if I already went and if I paid.
[CUSTOMER][NEUTRAL] Over $2000 you're gonna pay me my $2000 right?
[AGENT][NEUTRAL] And that reflects on the explanation of benefits that if that amount was applied towards your deductible co-pay coinsurance.
[CUSTOMER][NEUTRAL] In simple terms.
[CUSTOMER][NEUTRAL] What if I satisfied it somewhere else?
[AGENT][NEUTRAL] We only pick up benefits if it, if it reflects an out of pocket for that charge amount. So if there was no out of pocket for this hospital bill, then there would be no benefit payable. We only pick up the out of pocket towards your deductible, co-pay, co-insurance.
[CUSTOMER][NEUTRAL] Why does it have to be that particular date?
[CUSTOMER][NEUTRAL] What?
[CUSTOMER][NEGATIVE] That is, that sounds like a scam to me. OK, wait a minute, so.
[CUSTOMER][NEUTRAL] If
[CUSTOMER][NEUTRAL] If I get, what if I use up and I and I already paid my deductibles somewhere else.
[AGENT][NEUTRAL] For another data service or within this time frame for this data service?
[CUSTOMER][NEUTRAL] And so it
[CUSTOMER][NEUTRAL] Either way,
[AGENT][NEUTRAL] So whatever EOB that shows that was applied towards your deductible, then we will pick up those amounts that was applied towards your deductible, co-pay, co-insurance only.
[CUSTOMER][NEGATIVE] Wow, that is a really, I'm gonna have to notify my, my company. They got about 1000 employees using your gap insurance. That is really a tricky.
[CUSTOMER][NEUTRAL] Legal loophole you'll have there.
[AGENT][NEUTRAL] Yeah, since we're secondary, we only pick up your out of pocket towards your deductible co-pay, co-insurance.
[CUSTOMER][NEUTRAL] So you, you must pay a limited amount of claims.
[CUSTOMER][NEUTRAL] So you must be have a you a limited amount of claims that you pay you it's pretty lucrative company it looks like.
[CUSTOMER][NEUTRAL] Anyway, I, I will submit that. Then what about the one for.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Let's take a look at that one. You have everything.
[CUSTOMER][NEUTRAL] It's a Blue Cross Blue Shield thing.
[AGENT][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] And this is in regards to the new new mail that was submitted in?
[AGENT][NEUTRAL] For the dates of service.
[CUSTOMER][NEUTRAL] No, it was sent before and they said, oh, it's missing an address, all this other stuff. I spent so much time on this. I've never look, I have other insurance uh in the past where you just send stuff and they pay, but you guys are like really amazing.
[AGENT][NEUTRAL] So as far as on that previous claim that was processed.
[CUSTOMER][NEUTRAL] OK, this is the the date of service.
[CUSTOMER][NEUTRAL] State of service.
[CUSTOMER][POSITIVE] And you ought to, you ought to just to simplify your lives, and then you like it that way and do everything by mail.
[CUSTOMER][NEUTRAL] You would.
[CUSTOMER][NEUTRAL] The Actual date of service is the date, uh, will be [PII] total hip arthroplasty, 7-12-2023.
[CUSTOMER][NEUTRAL] [PII] was a surgeon, [PII].
[CUSTOMER][NEUTRAL] And there's a specific charge for that date, OK?
[CUSTOMER][NEUTRAL] And so that's what they paid.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me take a look.
[CUSTOMER][NEUTRAL] And then uh [PII].
[CUSTOMER][NEUTRAL] Uh, for images, so it's $7000.
[CUSTOMER][NEUTRAL] That's what they paid.
[CUSTOMER][NEUTRAL] So what, how are you?
[CUSTOMER][NEUTRAL] And it's got the Blue Cross.
[AGENT][NEUTRAL] The date of service for for [PII].
[CUSTOMER][NEGATIVE] Oh, you stole your dick 7.
[CUSTOMER][NEUTRAL] One moment
[AGENT][NEUTRAL] You mentioned the, the, the July data service, the [PII].
[CUSTOMER][NEUTRAL] I got it right. I got it right here. One more, no [PII], that would be [PII].
[CUSTOMER][NEUTRAL] It was the day of surgery.
[CUSTOMER][NEUTRAL] And you can see it on the memorial bill.
[CUSTOMER][NEUTRAL] And then you've got a Blue Cross Blue Shield.
[CUSTOMER][NEUTRAL] And that's how they, the way they send it. Let's see what they did for [PII]. They send the whole year.
[CUSTOMER][NEUTRAL] [PII] right there.
[CUSTOMER][NEUTRAL] Outpatient surgical center.
[CUSTOMER][NEUTRAL] They paid $25,000.
[CUSTOMER][NEUTRAL] On [PII]
[CUSTOMER][NEUTRAL] And then they paid again
[CUSTOMER][NEUTRAL] 6000 so [PII] they get paid a bunch of stuff there.
[AGENT][NEUTRAL] Let me take a look. So it looks like that was actually processed, not under the outpatient benefits. So that was an outpatient surgery performed on [PII]. Looks like we only received a bill for a physician for that charge.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Let me see if we have the explanation of benefits for that data service for [PII].
[CUSTOMER][NEUTRAL] Well, they, they send all of it like that. I mean it's like.
[CUSTOMER][NEUTRAL] It's a whole year.
[AGENT][NEUTRAL] We don't have the explanation for benefits for [PII] for that procedure.
[CUSTOMER][NEUTRAL] OK, but there's a long list of stuff, and then if you look at down through, that's what they said because they do it for the whole year [PII]. Look at the date.
[CUSTOMER][NEUTRAL] That's what they paid.
[AGENT][NEUTRAL] But this is not the document from Humana. We need the explanation of benefits from Humana. I don't show that we have it.
[CUSTOMER][NEUTRAL] It's not humanity any longer.
[CUSTOMER][NEUTRAL] It's no longer Humana, it's Blue Cross, Florida Blue.
[AGENT][NEUTRAL] Blue Cross. I don't show that we have the EOB for that date.
[CUSTOMER][NEUTRAL] Oh my gosh, it's a long document, about 10 pages.
[CUSTOMER][NEUTRAL] Submitted for that date and then it's Memorial Hospital.
[CUSTOMER][NEUTRAL] You, I, I have a confirmation of the fax I sent you.
[AGENT][NEUTRAL] So on the documents that we did receive on the new mail, is that what is in is in those documents, the new mail you submitted in? OK.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, so in this Florida blue document statements, I do not see a date for [PII].
[CUSTOMER][NEUTRAL] Yes, I see, I, I saw it clearly. Look, look through the dates. 712.
[CUSTOMER][NEUTRAL] So what is the date then the bill number.
[AGENT][NEUTRAL] From the EOB that you submitted, it looks like the pages that you submitted to us, it looks like pages one through.
[CUSTOMER][NEUTRAL] OK, go through the dates on the left hand column.
[CUSTOMER][NEUTRAL] 712
[AGENT][NEUTRAL] You submit those pages 1 through 6, and as I'm looking through each data service, page 2 shows dates of services beginning from [PII].
[AGENT][NEUTRAL] And then it goes up to page 6, which goes to [PII], and within those days, I'm not seeing anything for [PII].
[CUSTOMER][NEUTRAL] No, wait, wait, wait, wait, wait.
[CUSTOMER][NEUTRAL] No, no, no, no, forget about it. Oh, no, it's, it's, do you see that it's for the Memorial Hospital at the top of the page?
[CUSTOMER][NEUTRAL] You see Memorial Hospital, the whole bill for Memorial Hospital?
[AGENT][NEUTRAL] You look further back.
[AGENT][NEUTRAL] Let me keep looking.
[CUSTOMER][NEUTRAL] And then you have an attachment that says [PII] annual health statement from Florida Blue.
[CUSTOMER][NEUTRAL] Then you go through that and you go to page.
[CUSTOMER][NEUTRAL] Phase 3 of 8, wait a minute, no 4 of each.
[CUSTOMER][NEUTRAL] So 3 of each.
[AGENT][NEUTRAL] OK. Give me one moment, Mr. [PII]. I'll put you on a brief hold. It's 31 pages here, so give me one moment so I can look a little further.
[CUSTOMER][NEUTRAL] 3 of 8.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Thank you for holding, Mr. [PII]. So within those documents that you submitted us from Florida Blue, what you submitted to us is a health statement. This is not the actual explanation of benefits. If you will look at that document that you submitted in for [PII].
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] If you look at that claim receipt where it has Humana listed, this will kind of give you an example of what the explanation of benefits is it would kinda show you what was applied towards either your deductible, coinsurance or those amounts.
[AGENT][NEUTRAL] This here is just a health statement summary. This is not the actual explanation of benefits from Florida Blue. We still need the explanation of benefits which will show what was applied towards your deductible co-pay co-insurance amounts.
[AGENT][NEUTRAL] I do see the [PII], but this is, this is only just the health statement.
[CUSTOMER][NEGATIVE] Oh my gosh, you make it really complicated.
[AGENT][NEUTRAL] The explanation of benefits will show what was your deductible co-pay coinsurance amount for for each of those um providers listed for the charges that you're filing a claim. So for the hospital charge, it would show what your out of pocket was towards your deductible, co-pay, co-insurance.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEGATIVE] You know what, let me talk to your supervisor. I wanna talk to your supervisor.
[AGENT][NEUTRAL] OK, one moment, Mr. [PII].
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][POSITIVE] Good morning and thank you for calling APL. This is [PII]. How may I help you?
[AGENT][NEGATIVE] Good, good morning, [PII]. It's [PII]. I have an insured that's on the phone that's upset and want to speak to a supervisor. I was trying to get [PII] or [PII] but they're not available and [PII]'s not in today.
[CUSTOMER][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It's on policy 1986454. It's on a [PII] Dures.
[CUSTOMER][NEUTRAL] It's supposed to.
[AGENT][NEUTRAL] He was calling on the claim we most recently processed, which is at [PII].
[AGENT][NEGATIVE] He was calling on the dates of service that we asked for the EOB that [PII], and he also inquired about that [PII]. It looks like that was an outpatient procedure, but it was denied incorrectly.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then he sent in some new claims in regards to a data service of [PII]. I told him we receive those documents and they weren't reprocessed yet. I explained that we need the explanation of benefits on these claims to consider benefits. He's upset and he feels like this health statement that was most recently submitted in in the new mail is sufficient.
[AGENT][NEUTRAL] No, I told him we need the E.
[CUSTOMER][NEUTRAL] Have you looked at that?
[AGENT][NEUTRAL] Yeah, I looked at it.
[AGENT][NEUTRAL] It only shows what his.
[CUSTOMER][NEGATIVE] It's not sufficient.
[AGENT][NEUTRAL] It only shows his cost. It don't show what was applied towards his. It doesn't tell us what was in.
[CUSTOMER][NEUTRAL] It's a deductible cover incur.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So I tried to explain it to him.
[CUSTOMER][NEUTRAL] Um.
[AGENT][NEUTRAL] That we need the ELB that shows his out of pocket on his deductible copay coinsurance.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, you said first date was [PII].
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Where we ask for the EOB we still need that.
[AGENT][POSITIVE] Yes, we still need that.
[CUSTOMER][NEUTRAL] Get
[AGENT][NEUTRAL] And then on that claim 7, 12 or 23, it looks like they had a hip, hip replacement or something, but the examiner did process that under the offices which it really shouldn't have been based off that particular procedure, but we still don't even have the EOB for that data service.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Mm, we, we can't go by the procedure. Do we have documentation showing that it was outpatient?
[AGENT][NEUTRAL] Well, no, we don't. I was just looking at the procedure since they did a hip, they did an arthroplasty. Do they normally do that or not and then
[CUSTOMER][NEUTRAL] You would think.
[CUSTOMER][NEGATIVE] No, I don't know what they're capable of doing. I would think not.
[AGENT][NEUTRAL] Well, you're right. OK. Well, it was denied, but we don't have any, we don't have the facility bill for that one.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It looks like we got on that health statement. Let me go back. I think within that health statement, it has a facility on that one.
[CUSTOMER][NEUTRAL] OK, and
[AGENT][NEUTRAL] For [PII].
[AGENT][NEUTRAL] Yeah, he, yeah, he did. It was a surgery center for [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, within that new mail that we received under the health statement, it is an outpatient surgery for the [PII], but again, I had expressed and we need the EOB.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Deductible copay card OK 1986454.
[CUSTOMER][NEUTRAL] And I have 2 clients.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] And then also on the.
[CUSTOMER][NEUTRAL] Who's he with Florida Blue?
[AGENT][NEUTRAL] Yeah. Mhm.
[CUSTOMER][NEUTRAL] Hold on, my own base is trying to come up.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] don't.
[CUSTOMER][NEUTRAL] Statement this is not a bill.
[CUSTOMER][NEUTRAL] Florida blue.
[CUSTOMER][NEUTRAL] Deductible of pocket that you made.
[CUSTOMER][NEUTRAL] New York coast.
[CUSTOMER][NEUTRAL] I think he has to click into the client.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All right. I'm ready.
[AGENT][NEUTRAL] OK, let me get him on.
[AGENT][POSITIVE] Thank you for holding, Mr. [PII]. I have [PII] on the line and she's gonna assist you moving forward. Is there anything else that I can assist you with today, Mr. [PII]?
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][POSITIVE] That's it thank you.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][POSITIVE] Good morning Mr. [PII] um.