AccountId: 011433970860
ContactId: c6f3588f-9790-4902-a807-153dd0916fee
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1017979 ms
Total Talk Time (AGENT): 540572 ms
Total Talk Time (CUSTOMER): 327164 ms
Interruptions: 3
Overall Sentiment: AGENT=0.2, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/26/c6f3588f-9790-4902-a807-153dd0916fee_20250326T19:16_UTC.wav
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[AGENT][NEUTRAL] For contacting APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII]. I had, um, submitted some claims, and I'm really just trying to understand your guys' process.
[CUSTOMER][NEUTRAL] This would be my first time submitting claims.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Of course. What, what's your policy number? I, I, we could look that up and see how it's going.
[CUSTOMER][NEUTRAL] OK, 002510 uh 6045.
[AGENT][NEUTRAL] OK, thank you. If I could verify your uh date of birth and the phone number, please, ma'am?
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] [PII] of
[CUSTOMER][NEUTRAL] Uh [PII].
[AGENT][NEUTRAL] And is there a, uh, I just need to verify your, your phone number, please. I need to make sure I've got the right information.
[CUSTOMER][NEUTRAL] Oh, I'm sorry, [PII].
[AGENT][POSITIVE] OK, thank you so much. So uh let's see what we have here.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] I'm just checking what uh what you turned in.
[CUSTOMER][POSITIVE] Oh cute.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Now, was this for dental or vision services uh that you just turned in?
[CUSTOMER][NEUTRAL] No medical, no medical.
[AGENT][NEUTRAL] Yes sir.
[AGENT][NEUTRAL] OK, well let me try again. Let's see.
[AGENT][NEUTRAL] What
[AGENT][NEUTRAL] OK, so you said 251.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 6045.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] And let me pull my card again sorry.
[CUSTOMER][NEUTRAL] 205160445
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] I had 2 medical claims that I had.
[CUSTOMER][NEUTRAL] Submitted
[CUSTOMER][POSITIVE] And I paid my copay over there so I should be reimbursed for those. So that's what I submitted for the reimbursement of my co-pay.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Of course, let me, and I do apologize. I don't know why, and this is just my computer is going up and down. OK, you said 20.
[AGENT][NEUTRAL] But
[CUSTOMER][NEUTRAL] 51
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] 2051.
[CUSTOMER][NEUTRAL] Please
[CUSTOMER][NEUTRAL] 6045.
[AGENT][NEUTRAL] OK, that's what
[CUSTOMER][NEUTRAL] And I submitted them online. I have an account online, so right now it says process, so but it doesn't. I and I set up the direct deposit.
[CUSTOMER][NEUTRAL] And I just wanted to know the process means it's completed and if so, like.
[CUSTOMER][NEUTRAL] When do I see a payment?
[CUSTOMER][NEUTRAL] What does process mean when it says status?
[AGENT][NEUTRAL] It means that they have, uh, that they have actually looked at your claim and that they have, uh, uh, they have decided what they're going to do with it, uh, whether they're gonna pay it or not pay it, and I'm not showing it coming up here on my end, but what it will do is, uh, if, if it, it will update to a payment, um, if it.
[CUSTOMER][NEUTRAL] I can give you the confirmation number.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] I don't know what you need because.
[AGENT][NEUTRAL] And it's
[AGENT][NEUTRAL] Yeah, cause it's
[CUSTOMER][NEUTRAL] Because if you're not seeing it because the thing is too, I called to ask about um my claim and my doctor's office was originally they submitted it, right? The, the second one, the first one they did it, the second one they did.
[CUSTOMER][NEGATIVE] But then I called you guys and you're like oh they've never submitted anything.
[CUSTOMER][NEUTRAL] So, but I called to confirm that they submit it, submitted it. So then they're like, well you can submit it on your own. So then I submitted both of them, the previous one because I never said anything about the previous one.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] So yeah, so now you're saying you can't see what I've submitted because then I called to confirm that you guys had received it and it and if the documents that I had uploaded were the correct documents because like I said this is my first time doing this so if I learn how to do it then I can do it on every time I myself every time.
[AGENT][NEUTRAL] Sure, of course.
[AGENT][NEUTRAL] Well, let me go ahead and see if I can't, uh, if I, if you don't mind spelling out your last name for me, I'll just try that as well.
[CUSTOMER][NEUTRAL] Sure. It is. Uh, my last name is [PII]
[AGENT][NEUTRAL] And your first name is
[AGENT][NEUTRAL] To
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] Perfect, perfect. Thank you so much. OK. Try it again.
[CUSTOMER][NEUTRAL] I have a claim number also.
[AGENT][NEUTRAL] OK, we'll probably have to get to that in just a second. Let's see.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me try here again.
[AGENT][NEUTRAL] Yeah, that's what, OK, that's.
[AGENT][NEUTRAL] Well,
[AGENT][NEUTRAL] There's a Doctor [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Is it
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Well, the reason I was, I was asking, [PII], cause it, it looks like they're saying that it's for uh dental or vision. So let me just see what, what we have here. I'm just gonna
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] No, he's a physician.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] It's just that uh I'll just uh look this up because uh because uh um vision and dental aren't covered. So let me just.
[CUSTOMER][NEUTRAL] I know. I also have
[AGENT][NEUTRAL] Yeah, let's just see what we have here.
[CUSTOMER][NEUTRAL] Yeah, so tell says do you guys need some codes or what do you need? I mean.
[AGENT][NEUTRAL] No. Let's just check here.
[CUSTOMER][NEUTRAL] Yeah, I don't know why I would say that.
[CUSTOMER][NEUTRAL] It says office visit on non micro.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, it doesn't
[CUSTOMER][NEUTRAL] He is an MD.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And you guys, I mean, I found them off of, well, no, not uh off of my medical.
[AGENT][NEUTRAL] Right. So, Doctor [PII], let's see.
[AGENT][NEUTRAL] I'm just looking at the CPT codes now, so that's, I'm just waiting and I apologize my computer is just kind of lagging here, so let me just see what we've got here.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Well,
[AGENT][NEUTRAL] OK, so that's, it looks like on one of these that there were, there were several CPT codes and that's actually that what that means is just the codes of of what they're doing. So one of them is D as in David 2750.
[AGENT][NEUTRAL] And that is for a crown, um.
[AGENT][NEUTRAL] A, a crown on your tooth.
[CUSTOMER][NEUTRAL] What?
[AGENT][NEUTRAL] That that's what I'm looking at here. This is, so let me just check.
[CUSTOMER][NEUTRAL] I mean I did have that, but he's not the one that did that.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] So let's see.
[AGENT][NEUTRAL] Just gonna
[CUSTOMER][NEUTRAL] Let me go on that.
[CUSTOMER][NEGATIVE] That is so weird.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Well, maybe it's the paperwork, but no, it says his name right on there so unless the insurance people wrote up that wrong for the wrong dentist but I Aetna, Aetna because I pulled the the documents right from my insurance.
[AGENT][NEUTRAL] Huh.
[AGENT][NEUTRAL] Sure, of course.
[AGENT][NEUTRAL] Let's see what we have here. I'm just going there there was uh another set of of documents here and I'm just going through them and we can.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] So we
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] OK, so I'm, I'm looking at the visit for [PII]. This is for Doctor [PII]. Um, now, there was an office visit on that date that your, your policy doesn't cover office visits, so that, that wasn't covered. There was uh there was also a, well, I'm not showing, let me just check. Let's see.
[CUSTOMER][NEUTRAL] What?
[CUSTOMER][NEUTRAL] What do you mean?
[AGENT][NEUTRAL] Uh, let's see what your benefits are first. Let's, let's go over that. Let's go over your benefits.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so, uh.
[AGENT][NEUTRAL] Yes, so this is, um, so what we cover our inpatient services, inpatient hospital, um, and that could be anything, uh, ambulatory, uh, um, surgery and inhospital event, you know, where you're actually in the hospital, um.
[AGENT][NEUTRAL] There's also outpatient services. Now, the outpatient services are, are uh include outpatient surgery, cancer, independent labs, diagnostic testing, durable medical, infusion therapy, dialysis, kidney dialysis, um, outpatient, uh, um, physical therapy, uh, treatment within a physician's office, um, the ER, urgent, um, urgent care, uh, sleep, uh, if you had sleep apnea, there's that.
[AGENT][NEUTRAL] Um, outpatient, uh, speech patho, uh, if you needed, uh, any sort of speech therapy.
[AGENT][NEUTRAL] Um, but the office visits, uh, treatment within the physician's office is covered for just about any possible, uh, place of service, but the office visit co-pay is, is not going to be covered on these policies. So first of all, the office visit co-pay is.
[CUSTOMER][NEUTRAL] Oh, I was
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] That I was told when we signed up or whatever that they cover office our copays.
[AGENT][NEUTRAL] Oh, I am sorry. Yeah, that's no co-pays, no.
[CUSTOMER][NEUTRAL] So, you're telling me.
[CUSTOMER][NEUTRAL] So instead of instead of going to see my doctor, if I went to urgent care and got a bill from there, you guys would cover it? Is that, is that what I think you said urgent care.
[AGENT][NEUTRAL] Yeah, urgent care is covered, yes, um, but the, but the office visit co-pay is not.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] After
[CUSTOMER][NEUTRAL] In order not to pay anything, I would, I could go, I should just go see an urgent care person.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Uh, let's see what else there is on the claim.
[CUSTOMER][NEUTRAL] That's fine with me.
[AGENT][NEUTRAL] Uh, let's see.
[AGENT][NEUTRAL] And I'm sorry, I'm just going through your, your claim here and see what we've got.
[AGENT][NEUTRAL] OK, then we also have a doctor [PII] and I'm, I'm not even, I don't want to uh try to um pronounce his name. So uh this is where we have um uh your your porcelain crowns, your dental bite wings, periodic oral um uh evaluation, you know, where they look at your teeth, uh.
[AGENT][NEUTRAL] They charged you $1,035 for that and uh it looks like uh your um Aetna didn't pay it. But your, your um uh because this is dental, your um
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Your gap insurance uh wouldn't pay it, as well. Now, let's just say that, that, uh, that Aetna did put this towards your deductible, co-payment or co-insurance. Your, your gap insurance still doesn't cover, it covers medical events, but it's never gonna cover vision or dental. So, so there's that, um, so there, there's that. Let me just check.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] But I didn't think I admitted.
[CUSTOMER][NEGATIVE] I didn't submit it. I didn't even submit that work.
[AGENT][NEUTRAL] Oh yeah.
[AGENT][NEUTRAL] Uh, well then, I'm looking at it. Um, I don't know what to tell you. Uh, it's, it's the, w[PII] do we got here? Your claims up close. Uh-huh.
[CUSTOMER][NEUTRAL] Uh, it
[AGENT][NEUTRAL] Yeah, I'm, I'm
[CUSTOMER][NEUTRAL] Yeah, mine, mine is so on [PII] my documents [PII], so then the second one is.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Doctor [PII], I don't see the other doctor on the paperwork I submitted, but I can see the.
[AGENT][NEUTRAL] Yeah, it should, well, I, yeah, I've got it. It looks like, it looks there were 9 documents that were submitted. Let me see what I've got here. So we've got um uh.
[CUSTOMER][NEUTRAL] So I, uh, which was a state for [PII] and it says doctor visit 10-14-24.
[CUSTOMER][NEUTRAL] Is that the one you're looking at?
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Uh, no, I don't have anything for [PII]. I, you know, I'm wondering what, uh, let me tell you the dates of service that I have. I have [PII] and I have, uh, what I've got is, uh.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Now, there is uh [PII], excuse me, [PII].
[AGENT][NEUTRAL] That might be, that's also an office visit. There's one, there's a.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Uh, yeah, that's uh.
[CUSTOMER][NEUTRAL] Payment date well that's a.
[AGENT][NEUTRAL] Now, there's also, as I mentioned before, the [PII], uh dental uh documents. So, um, that's what I've got.
[CUSTOMER][NEUTRAL] Yeah, I didn't, I met any.
[CUSTOMER][NEUTRAL] So it must be my insurance submitting it. I have no idea because I didn't submit those.
[AGENT][NEUTRAL] No, your insurance wouldn't have. OK, well, that's, um, the only thing I can tell you, OK, the only thing I can tell you is that it went somehow the other it went through your portal, but that's, that's what your claim means, that's what your claim says. So on the, on the claim where it says process, what, what we, what we received, um, however it went through the portal, um.
[CUSTOMER][NEUTRAL] I didn't submit though.
[CUSTOMER][NEUTRAL] The number is claim number 358-0214.
[AGENT][NEUTRAL] That's correct, yes. So that is for um office visits for [PII], um, which, uh, you know, the, the, the office visit isn't covered and then the other thing that Doctor [PII] did uh was not um uh was denied by your, uh, uh.
[AGENT][NEUTRAL] Right, uh, at NESA, there was nothing to be paid on that. And then there were the, um, [PII], uh, dental visit, uh, for Doctor uh [PII]. I can't pronounce his last name.
[AGENT][NEUTRAL] And then the other thing that we have.
[CUSTOMER][NEUTRAL] Oh, maybe a day
[AGENT][NEUTRAL] Uh, let's see.
[AGENT][NEUTRAL] And there's the other things that we have now, if there's anything else, I'm not seeing anything else besides this, so if there's anything that is not listed on here, um, that, that, uh, you know, that, that you feel should be, you can always go ahead and, and uh re uh resend it to us because it's, it's possible that, that maybe we just didn't get it. But those are the things that we got with, with it.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Well,
[CUSTOMER][NEUTRAL] Hi
[CUSTOMER][NEUTRAL] Yeah, so, but those are all on that claim, the 358-0214.
[AGENT][NEUTRAL] Yes.
[AGENT][POSITIVE] Uh, that's correct, yes.
[CUSTOMER][NEUTRAL] Really?
[CUSTOMER][NEUTRAL] Because now I'm thinking that when I did go to my dentist, I did give them all my insurance cards so they may have submitted the dental one could not and me not knowing that it's just with medical so the dentist's office, but I don't see how they would be on the same claim.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Well, we're, however it is, um, however it worked out, [PII], we're, we're showing that it went through the portal. We, we're showing that it went through, through, uh, the, uh, through your portal. So, um, normally if uh if the provider, uh, um, sends it to us, it goes through a different portal.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] Make that
[AGENT][NEUTRAL] It's, it's just completely different.
[CUSTOMER][NEUTRAL] It, yeah, I guess I didn't submit those papers that you're telling me.
[AGENT][NEUTRAL] OK, well, well, one, however it is that they, they came into being, um, that's what we received and that's what's on that claim. Now if, if there's anything else that you feel should have been on there, um, there's a [PII] offices that, um.
[CUSTOMER][NEUTRAL] That's, that's
[AGENT][NEUTRAL] If, if there's anything that else that should be on there that you feel uh is not, you can, you can always go ahead and submit it to us.
[AGENT][NEUTRAL] But, but that is what we, that's the documents we received.
[CUSTOMER][NEUTRAL] Oh, you're saying
[CUSTOMER][NEUTRAL] Really no point if you don't, I wouldn't cover my um doctor's visits, but.
[AGENT][NEUTRAL] Well, they, they cover treatment within the physician office. They, they just don't cover your offices at co-pay.
[CUSTOMER][NEUTRAL] Um, but I do know now.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Well, I have insurance to cover my offices, OK, alright, so I just know for next time you go to the emer uh the emergency room or.
[CUSTOMER][POSITIVE] Urgent care. Thank you so much for your help. Have a good day. Bye.
[AGENT][POSITIVE] OK. Well, thank you for contacting you too. Have a good day.