AccountId: 011433970860
ContactId: c8dce1d6-741f-4be5-beae-3ecbbaaf77c6
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 611169 ms
Total Talk Time (AGENT): 198479 ms
Total Talk Time (CUSTOMER): 320101 ms
Interruptions: 0
Overall Sentiment: AGENT=2.2, CUSTOMER=1.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/21/c8dce1d6-741f-4be5-beae-3ecbbaaf77c6_20250521T19:56_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Um, I'm, I'm so sorry. What, what's your name?
[AGENT][NEUTRAL] My name is [PII].
[CUSTOMER][NEUTRAL] Hi, [PII]. How are you? My name is [PII]. Uh, I am, um, well, I, I have, um, American Public Life as a gap.
[CUSTOMER][NEUTRAL] And I am having a situation with a deductible that uh you guys have stated to the place where I had my colonoscopy done, saying that you're not gonna cover it. So I don't know if you can help me with that. Cause I called yesterday and the day before yesterday and I was told that it should be covered. So if you can help me, it would be wonderful.
[AGENT][NEUTRAL] OK, what is your policy number?
[CUSTOMER][NEUTRAL] It's 1,306,740 M as in mother, L as in Lima, well, on the, in the hospital, it's a 7 and an 8 for an outpatient.
[AGENT][POSITIVE] OK, thank you so much and may I have your date of birth please?
[CUSTOMER][NEUTRAL] Yes, of course. [PII].
[AGENT][POSITIVE] Thank you and your callback number if we are disconnected please.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you so much. And verify for me your mailing and email addresses.
[CUSTOMER][NEUTRAL] [PII]. That's my email and my home address is [PII].
[AGENT][POSITIVE] OK, thank you very much for the verification process, OK.
[CUSTOMER][POSITIVE] OK, no problem.
[AGENT][NEUTRAL] Give me one second that you called yesterday in regards to a procedure. OK, I have that claim number. Give me one moment.
[CUSTOMER][POSITIVE] Yes, of course.
[CUSTOMER][NEUTRAL] Yeah, the day before yesterday.
[AGENT][POSITIVE] Let me get that looked up for you, yes ma'am.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Please
[AGENT][NEUTRAL] OK, that was inventory here. Give me one second just to pull up that claim for you, OK? Give me one moment please. Thank you so much for your patience.
[CUSTOMER][POSITIVE] Yes, of course. Thank you. Thank you very much.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] OK, so this was for date of service of [PII]. I just want to make sure of that date. OK, thank you.
[CUSTOMER][POSITIVE] Correct.
[CUSTOMER][POSITIVE] Correct, correct. For the colonoscopy, endoscopy, and everything else.
[AGENT][NEUTRAL] OK, that's colonoscopy.
[AGENT][NEUTRAL] So right now what I'm doing, I'm looking over the claim that was submitted to us, bear with me, I'm almost there.
[CUSTOMER][POSITIVE] Yes, of course.
[CUSTOMER][POSITIVE] No, no problem, no problem.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, let me just make sure you can hear me. OK, so in looking at the claim that was submitted to us for payment, it was denied correctly. It shows that.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The bill amount was $5500.
[AGENT][NEUTRAL] The allowed the allowed amount was $1,675.81.
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] And it shows that your primary paid $1,675.81. There are no charges applied to your co-insurance, co-pay or deductible.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] That's
[CUSTOMER][NEGATIVE] But the weird thing is that the bill that I have in front of me, that is what they're sending me, is the charge is $5500.
[CUSTOMER][NEUTRAL] Then it says insurance write-off $3,995. The insurance payment was 1 $1,102.31. There's a correction of the write-off of minus $236.46 and then patient due is $638.74.
[CUSTOMER][NEUTRAL] Uh, that is the bill that I have. So the numbers that you're giving me are a little different and what I also did was um
[CUSTOMER][NEUTRAL] I have also printed out here the um the explanation of benefits from the insurance, and it says my claim status and it says that my total cost that is my deductible, my deductible is $638.74.
[CUSTOMER][NEUTRAL] Um, and it says, like, like you said over here that is different from uh what I have over here that uh the plan paid $1,685.77.
[CUSTOMER][NEGATIVE] So, but they're, they're uh they're giving me a deductible that I have to pay for $638. And the gap is supposed to be covering whatever my deductible is. So, I don't understand why.
[CUSTOMER][NEGATIVE] You guys cannot cover it.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That's where my question is.
[AGENT][NEUTRAL] OK, um, the claim that was billed to us, they billed us with one procedure code which was the $5500 which was billed to us. And with that, um, with that, um, the allowed amount was $1,675. I'm sorry, the allowed amount was $1,675.81 and that is what your major medical paid.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Now if there is a corrected claim that needs to be sent into us and we need that in our office to process it. However, it was processed correctly with no payment.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] I mean, uh
[CUSTOMER][NEUTRAL] So, from, from what you have with you.
[CUSTOMER][NEUTRAL] It doesn't appear anywhere that there's a deductible that is my responsibility.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Correct. That's, that, that's what, that's what you need? OK.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, I, because then I don't know how, how to, because I mean, I, the only thing I did was I went into the actual insurance page and I printed it.
[AGENT][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] This is what I printed on Monday. So that's why it's like, I, I, I, I don't.
[CUSTOMER][NEGATIVE] I don't know how, I mean, should I be sending you this stuff? I, I, I don't know, I don't know who's supposed to, to, to provide you with, with whatever is the insurance stuff.
[AGENT][NEUTRAL] OK, it appears.
[CUSTOMER][NEUTRAL] It's, it
[AGENT][NEUTRAL] I'm sorry.
[AGENT][NEUTRAL] It appears that there may have been a a claim that has been corrected because the only thing that we show in our system is one procedure code. Now I do see another procedure code that was not listed on the bill that was sent in by the facility. So if the facility needs to send us an updated bill, they can do that and we will of course review that and process it accordingly, but per these.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I mean, because the problem is that I, I, I, and I'm, I'm sorry to, to, to, to interrupt you.
[AGENT][NEUTRAL] That's OK.
[CUSTOMER][POSITIVE] Uh, I had, I spoke with the person from the, uh, the Pleasantalle because I made them call you guys.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] I asked them to call, and they spoke with a girl called [PII]. And [PII] was like, no, there's nothing. I mean, you are the 2nd person that I talked to that tells me, well, I think that there's a miscommunication because I spoke with [PII] the other day, and she was like, yeah, I mean, it, it seems that there could be a miscommunication there, that there is something missing, that there might be a code missing.
[CUSTOMER][NEGATIVE] But when I have these people talk to you directly, the answer was like, no, there's nothing, it is, and that's it. So, how can I go about it? These people are not gonna call you guys again, so, I don't know what to do.
[AGENT][NEUTRAL] OK. If you can get an updated bill from the, from Pleasantville Ambulatory care that shows that both procedure codes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, hold on a second.
[CUSTOMER][NEUTRAL] OK, we need the procedure.
[CUSTOMER][NEUTRAL] Codes, OK.
[AGENT][NEUTRAL] We need an updated
[CUSTOMER][NEUTRAL] The
[AGENT][NEUTRAL] Deal
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] With the two procedure codes because one is missing, correct? OK, 1.
[AGENT][POSITIVE] Correct.
[AGENT][POSITIVE] That is correct, yes.
[CUSTOMER][NEUTRAL] OK, which one, can you, could you please, the one that you have is what number? Or what?
[AGENT][NEUTRAL] The one
[AGENT][NEUTRAL] OK, the procedure code that we have that's on the claim and the EOB is 45,380.
[CUSTOMER][POSITIVE] Thank
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 380. OK.
[AGENT][NEUTRAL] 45,380. The procedure code that is missing.
[CUSTOMER][NEUTRAL] Right?
[AGENT][NEUTRAL] On the bill is 43239.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 239. OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so that's the one they're missing. But that's the one that could be the one that should cover for that. If it, if it's, if it's reviewed and it's approved, that's what I mean.
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, OK.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Let me call them.
[CUSTOMER][POSITIVE] Oh my God, I think I'm spending so much time on the phone. That's no fun. So I do appreciate your help on this. Thank you very much. Let me call them and see what I can, I can do to get this uh resolved.
[AGENT][POSITIVE] I'm sorry
[AGENT][NEUTRAL] OK, yes, ma'am.
[CUSTOMER][POSITIVE] I appreciate once again your help. Thank you very much.
[AGENT][POSITIVE] You're very welcome and thank you so much for calling APL. Have a great day. Take care.
[CUSTOMER][POSITIVE] Thank you. Bye-bye.
[AGENT][NEUTRAL] Bye bye.