AccountId: 011433970860
ContactId: beff4f8c-bd30-4fe7-a2c5-f4e67682043a
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 752549 ms
Total Talk Time (AGENT): 234968 ms
Total Talk Time (CUSTOMER): 439887 ms
Interruptions: 1
Overall Sentiment: AGENT=0.7, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/03/beff4f8c-bd30-4fe7-a2c5-f4e67682043a_20250403T21:35_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] [PII], I'm trying to file two claims, one for 2024 for [PII].
[AGENT][NEUTRAL] For
[AGENT][NEUTRAL] OK, is it for yourself?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEGATIVE] Yeah, they're gonna be gap claims.
[AGENT][NEUTRAL] OK, uh, do you have, can I get your name and your policy number, please?
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Yeah, my name is [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The claim the company that I have is APL.
[CUSTOMER][NEUTRAL] And the policy is 02564453.
[AGENT][POSITIVE] OK, thank you.
[AGENT][POSITIVE] OK, and how can I help you today?
[CUSTOMER][NEUTRAL] So I can't find on the form on the website. I'm trying to figure out what would be gap insurance like what claim form am I trying to find.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me uh see what we've got here. Let me verify a few pieces of information if you don't mind. Do you have a good callback number?
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And your date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And then your address?
[CUSTOMER][NEUTRAL] Uh, [PII].
[AGENT][NEUTRAL] And lastly your email address.
[CUSTOMER][NEUTRAL] Uh, [PII].
[CUSTOMER][NEUTRAL] Mattis, M A T I S at.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, so the claim form that you'll want to fill out is let me get that pulled up and give you the exact name, um.
[AGENT][NEUTRAL] So it's the med link claim form.
[CUSTOMER][POSITIVE] Medin claim form alright perfect.
[CUSTOMER][NEUTRAL] And then let me ask you a couple questions so I had talked to another representative a couple weeks ago and finally um I had to get detailed billing from, um, most of the the providers because their billing didn't have the details and the coding information on it so they since have sent me um detailed billing.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Or at least they tell me that that's what they sent me, you know, it's hard for me to tell because I don't really know what y'all are looking for but.
[CUSTOMER][NEUTRAL] Uh, I'm gonna assume that they're pretty well versed in that like one of them says detailed billing on it, so that pretty much says, you know, she's submitted the right stuff and then the other detailed billing that I have is pretty much all through the hospital and they actually sent it to my house it's tons of pages um so I'm gonna assume they also knew what they were doing but.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Is there anything else that I need to upload when I'm sending all so you know, these are just bills from the hospital, um, and from the doctors. Am I also uploading um.
[CUSTOMER][NEUTRAL] Uh, EOB from the insurance company.
[AGENT][NEUTRAL] Yes, we will need your
[CUSTOMER][NEUTRAL] That matches the billing?
[AGENT][NEUTRAL] Yes, we will need your primary explanation of benefits that shows how it paid and then um I will say so on the detailed billing.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, what we are looking for is.
[AGENT][NEUTRAL] You know, like the diagnosis code and then the procedures that were performed, so.
[CUSTOMER][NEUTRAL] So, um.
[CUSTOMER][NEUTRAL] Yeah, it's hard for me to even say what this might be.
[CUSTOMER][NEUTRAL] Let me just see.
[AGENT][NEUTRAL] Well, we'll, we of course will review it and then let you know exactly if something's missing.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][POSITIVE] And then you let me know right if it's wrong, right? OK, perfect.
[AGENT][POSITIVE] Yeah, of course, of course.
[CUSTOMER][NEUTRAL] OK, alright and then so I need my EOBs that'll match up to these bills, um, one of the one of the hospitals, uh, I don't know if you're familiar with it or not, but anyway, it's [PII] and so all of their billing goes through my chart and so you know it has bills that just go on forever, um, so I'm sure that you'll just sift through to see, you know, I'll send what I know covers the bill anyway.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, and then it's my understanding that the gap insurance will pay up to $1500 per year.
[CUSTOMER][NEUTRAL] Um, it's not per.
[AGENT][NEUTRAL] Uh, let me
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, let me pull up your policy real quick and anything I quote is not a guarantee of payment basic outline of your policy.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] Uh, let's see what we've got. Do you just have outpatient services that you're submitting?
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Yes, well, I think so, yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, you've got a.
[CUSTOMER][NEGATIVE] Like I didn't stay.
[AGENT][POSITIVE] $1500 per calendar year. That's correct.
[CUSTOMER][NEUTRAL] OK, so I'm gonna do [PII] because that's when all this mess started and then it went into [PII], um.
[CUSTOMER][NEUTRAL] What ended up happening is I had one provider that took the full payment of my deductible, which was like 2500 I guess.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Um, on a, on a credit card from my husband because they wouldn't do the procedure if I didn't pay the deductible because we had just changed insurances and they weren't showing that my deductible was paid.
[CUSTOMER][NEUTRAL] Anyway, um, so, but then they turned their bills in last minute. Uh, they were the last provider to turn the bills in, so.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][POSITIVE] Allied and APL were showing that they would have had gotten full payment from my insurance of which my insurance finally did pay them and then then they credited my husband's credit account so it's been taking a little while to get this all together.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Because we were trying to at least get our money back, but I did notice that I have another provider, it's actually the same provider that filed not only my health insurance but Gap insurance on another procedure, and GA paid them $63.
[CUSTOMER][NEGATIVE] Do I need to go tell them they owe me that back? Do they owe me it back?
[AGENT][NEUTRAL] Um, so we don't determine patient responsibility. That's what part of what, you know, as a secondary policy I do show we paid 6373 to Gainesville Eye Associates.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] That was for 12-9-2024, um, let's see what the bill charges were.
[AGENT][NEUTRAL] Uh, the bill charges were 587.
[AGENT][NEUTRAL] So you could call and you know I I don't know what your primary paid um.
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] Let me look at that real quick.
[CUSTOMER][POSITIVE] So they ended up getting paid in full for all their services because my deductible and out of pocket max is met.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So they ended up getting paid in full.
[AGENT][NEUTRAL] OK, so they haven't balance billed you or anything for that date correct if they were paid in full?
[CUSTOMER][NEGATIVE] Yeah, yeah, no, they, they won't, um, they did finally issue the credit like I said because I had to chase them down for it so as soon as they showed that they got paid from insurance, then they, they gave the money back but I'm thinking that they still owe me the $63.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me pull up what we received real quick.
[AGENT][NEUTRAL] Let's see
[AGENT][NEUTRAL] So on the claim, let me look at that. Give me just a moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] So all we can see on our side is they billed a claim for 587 and then they submitted your explanation of benefits that showed after primary paid all that was left was 6373 and then that's what we paid.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So we, that's, that's all the information we have, so.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Without looking at their portal and system and everything, I, I don't know for sure what they have in your system, on your side on the MyChart that shows.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] What transpired on this claim, so like I said, they billed 587.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] They showed
[AGENT][NEUTRAL] All that was left after your primary paid was 6373 and then that's what we paid them so.
[CUSTOMER][NEUTRAL] OK, and then that $63 is gonna be basically if I'm gonna get $1500 from APL.
[CUSTOMER][NEUTRAL] Right now one of those payments is gonna be short $63 because $63 went to them, correct?
[AGENT][NEUTRAL] That is correct, yes, that will take off of that 2024 $1500 benefit.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] So I just have to figure out how they're gonna, they're gonna have to rebuild it because it really should have went to my regular insurance, not my gap.
[CUSTOMER][NEUTRAL] Um, I don't think, uh, because everything else goes to my regular insurance first and then the gap.
[AGENT][NEUTRAL] Well, and we, and I'll tell you this, we, we will not process anything without your primary insurance processing at first. We will always deny your claim unless we have a primary explanation of benefits that shows it was processed through your primary, so.
[CUSTOMER][NEUTRAL] I don't know.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK, and so.
[CUSTOMER][NEUTRAL] So they must have gotten it processed through my primary.
[AGENT][POSITIVE] Yeah, this one that we were talking about, yeah, yeah, this was definitely.
[CUSTOMER][NEUTRAL] I just, yeah.
[CUSTOMER][NEUTRAL] What what is the date of services on that one?
[AGENT][NEUTRAL] That date of service is [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Doctor [PII].
[CUSTOMER][NEUTRAL] Yeah, so I really think that that was just a consultation.
[AGENT][NEUTRAL] It looks like it. There was a $500 office visit charge 504, and then um they billed another $83.
[AGENT][NEUTRAL] Uh, not sure what that code is.
[CUSTOMER][NEUTRAL] For pictures I think.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Think it's pictures.
[CUSTOMER][NEGATIVE] It was ridiculous.
[CUSTOMER][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] Yeah, weird.
[CUSTOMER][NEUTRAL] OK, um.
[CUSTOMER][NEUTRAL] And then they paid 63 what was it? 6360?
[AGENT][NEUTRAL] Uh, 6373. That's what we paid to the provider, yeah.
[CUSTOMER][NEUTRAL] Paid by gap.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And that would be APL. Alright, so I am going to download this, uh, meddling claim form, get it filled out for 2024, 25, I guess I've got to upload my explanation of benefits is one of my if I do an explanation because that's another thing I've Allied Insurance so.
[AGENT][NEUTRAL] Ex
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] If I do an explanation of benefits for [PII] and a full one for [PII], you guys will find what you need, right?
[AGENT][NEUTRAL] Yes, as long as we show that primary that it processed the claim, correct.
[CUSTOMER][POSITIVE] OK awesome all right well let me get to work.
[AGENT][NEUTRAL] Anything else I can
[CUSTOMER][POSITIVE] All right, thanks so much for your help. No, not right now. Thanks so much. Uh-huh, bye-bye.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK, thank you. Have a good evening.
[CUSTOMER][NEUTRAL] Uh-huh. You too. Bye-bye.
[AGENT][NEUTRAL] Right.