AccountId: 011433970860
ContactId: d02f7a18-dd43-4670-85ef-94c463cb145e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1279319 ms
Total Talk Time (AGENT): 463213 ms
Total Talk Time (CUSTOMER): 237594 ms
Interruptions: 2
Overall Sentiment: AGENT=0.7, CUSTOMER=-0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/18/d02f7a18-dd43-4670-85ef-94c463cb145e_20250418T13:39_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII]. I'm calling in reference to an invoice that I received um the from the Baptist Hospital, and they tell me that, um, the insurance did not pay their part of it, and I was calling to.
[CUSTOMER][NEUTRAL] Um, find out why.
[AGENT][NEUTRAL] OK, well, I can definitely look into the claim for you and see um what the outcome was. Ms. [PII], may I have a good contact number in case we're disconnected and your policy number?
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Yes, it's [PII].
[CUSTOMER][NEUTRAL] 9270.
[CUSTOMER][NEUTRAL] And I have a group number, is that the policy number?
[AGENT][NEUTRAL] No, um, it should say policy certification number. It might start with the 01 or 02.
[AGENT][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK, I have one that says in hospitals benefit certificate number.
[AGENT][POSITIVE] Yes, I can use that.
[CUSTOMER][NEUTRAL] OK, 02255705 M as in Mary, L as in Larry 7.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And I have your policy here. I just need you to verify your date of birth and the mailing address on file.
[CUSTOMER][NEUTRAL] Uh, mine is [PII], [PII].
[AGENT][POSITIVE] Thank you for
[CUSTOMER][NEUTRAL] This is under my husband's name.
[AGENT][NEUTRAL] OK, thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And was it a claim for you or your husband or one of the children?
[CUSTOMER][NEUTRAL] For me.
[AGENT][NEUTRAL] For you? OK.
[AGENT][NEUTRAL] And do you have the, do you know the date of service? Um, oh, it should be on the invoice.
[CUSTOMER][NEUTRAL] Um, no.
[CUSTOMER][NEUTRAL] Yeah, [PII].
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] And what's the name of the, um, you said it's from [PII]?
[CUSTOMER][NEUTRAL] Yes, West Kendal Baptist Hospital.
[AGENT][NEUTRAL] Is [PII].
[CUSTOMER][NEGATIVE] I also have a second invoice that shows that it wasn't paid from you guys.
[AGENT][NEUTRAL] Like an explanation of benefits?
[CUSTOMER][NEUTRAL] Um, no, it's another, um, another time I went to the hospital.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] And um we got we got another bill and then when I called the credit uh the invoice you know the [PII], they told me that um APL did not pay for this, the difference.
[AGENT][NEUTRAL] OK, let me look at these claims because there's 24 claims that came in for this data service. Let me look at them and the um denials or if they were paid, and then I'll be able to give you um answer to why.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] You're very welcome. Hold on one moment, OK?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[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][NEUTRAL] Hello, Mrs. [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Thank you so much for holding. I do apologize for that wait. So, I did figure out what happened. So there of the 4 claims that were received, um, 2 of the claims, um, I can give you the claim numbers if you need them, but two of the claims, the payable amount was applied to your emergency room deductible.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So for your policy, you have a $200 per person per occurrence deductible occurrence is anything of the same issue. Um, so like every time you go for your knee, that's an occurrence, and then if you go for your shoulder, that's another occurrence because it's a different issue. Um, and then the, it was paid though, um, $700 we did pay to the provider for the emergency room but um.
[CUSTOMER][NEUTRAL] OK. Uh-huh.
[AGENT][NEUTRAL] The emergency room benefit after that those two met the deductible, we were then able to pay the $700. You have a calendar year, um, maximum of $1000 so that's for the whole year, so the $700 is all that could be applied to that, um, which met the the $1000 maximum.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So we did
[CUSTOMER][NEUTRAL] That's for which uh invoice number?
[AGENT][NEUTRAL] Well, the invoice numbers from [PII], I won't have here. I can give you the claim numbers. Um, let me see, hold on one moment, let me go back to the claims.
[AGENT][NEUTRAL] I can give you the claim numbers and the
[AGENT][NEUTRAL] The total bill amount on the claims and then if it was applied to the deductible or paid.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, hold on one second.
[AGENT][NEUTRAL] OK, so the first one, well, let me start at the bottom.
[AGENT][NEUTRAL] Because it was 4 times. Hold on one second. 351.
[AGENT][NEUTRAL] Alright, so the first one was received on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It was claim number 3511331.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, the payable amount for that was applied to the deductible. Let me see if it shows.
[AGENT][NEUTRAL] Here what that was. Hold on one second.
[AGENT][NEUTRAL] I pull up the explanation of benefits. Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Oh, wait, I'm sorry, I misspoke. For this claim, it was denied because the outpatient benefit for the calendar year had been met, the $1000.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK, so this one that the one, well, the invoice that I have that ends at 872 is the one that was not paid.
[CUSTOMER][NEUTRAL] Because I'm sorry, what was that?
[AGENT][NEUTRAL] So I'm, I don't have the invoice numbers because that's coming from [PII]. I'm giving you the claim numbers and what happened if it was applied to the deductible, if it was paid, or if the, if the max was met for the year.
[AGENT][NEUTRAL] Because we did pay them $700.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, but they're two different, um, invoices, two different times that I went.
[AGENT][NEUTRAL] What's the total bill on your invoice on your invoices?
[CUSTOMER][NEUTRAL] Well
[CUSTOMER][NEUTRAL] Right now it's $1,663.04.
[AGENT][NEUTRAL] That's for both of them or that's one.
[CUSTOMER][NEUTRAL] No, that's just that's one invoice.
[AGENT][NEUTRAL] OK, and what's the next one?
[CUSTOMER][NEUTRAL] The other invoice was for 1,661 cents.
[AGENT][NEUTRAL] $1600.61. OK.
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] And that's [PII].
[CUSTOMER][NEUTRAL] For this one.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Well, for the one for [PII] is the one for 1,663.04.
[AGENT][NEUTRAL] OK, that's [PII]. OK, and then what's the data service for the 1600?
[AGENT][NEUTRAL] 61 cents.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Yeah, let me see.
[CUSTOMER][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] Like um.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I think it was, oh yeah, here it is in [PII].
[AGENT][NEUTRAL] OK. So now that I have this, let me go through these claims, match the um total bills, and then I'll be able to know which claim is which. Um, do you mind if I place you on just a brief hold?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] No problem.
[AGENT][NEUTRAL] Alright, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[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][NEUTRAL] OK, hello, Mrs. [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] All right, thanks so much for holding. So, for the two invoice, data service and amounts, we don't have a claim on file. So the [PII] of the four claims that we received.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 2 were from [PII].
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] One total of $504.
[AGENT][NEUTRAL] Hold on.
[AGENT][NEUTRAL] Let me read my lines correctly.
[AGENT][NEUTRAL] MBB MBB South [PII]. I'm sorry. So on [PII], only one was from [PII], two were from MBBRadilogy, and one was from South Miami um Hospital. The one from [PII] totaled $11,147.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] When you call them, let them know if the, if, if that is the full total bill, because sometimes they'll just send us like the portion after primary or something. If the 11 $1,147 is the correct total bill, then we pay $700 on that claim. If that, if
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Yeah, I had called them before. They told me it was 11,147.
[AGENT][NEUTRAL] OK, so we did pay to them $700 to that claim. Now the reason that it couldn't be paid more is because you only have $1000 for the whole year. So that $700 was all that was left for that year, for [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] What is that 1000 that you said I have left for the year? What exactly is that?
[AGENT][NEUTRAL] You have a calendar year maximum balance that we can pay towards your outpatient benefits. So like if you go to the ER, you go to the urgent care, that's all outpatient, we have $1000 that we can use towards those expenses each year.
[CUSTOMER][NEUTRAL] OK. OK. Um, and the other one, which is the
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] The one that's uh [PII].
[AGENT][NEUTRAL] So now that one, we only have one claim on file. Now, it did say [PII], but it didn't say West Kindle like the other claim. So, I have the total bills and their tax ID. If you want to let them know, hey, I called my insurance, they have one claim.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It's from [PII], but it didn't say West Kendall, and it is two different tax IDs. Tax IDs are like their property ID how we specify the different locations. So it does look like it's a different claim. If that is in fact true, then we don't have a claim on file from West Kendall.
[CUSTOMER][NEUTRAL] Um, OK, so, um, well, this one is rectangle. It says it on the, uh, invoice.
[AGENT][NEUTRAL] Right, so what I'm saying is the claim that we have here doesn't say West Kendall, so, but it does say [PII].
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] So, we don't.
[CUSTOMER][NEUTRAL] But is does it, is it the same amount 1,66304?
[AGENT][NEUTRAL] No, so we don't have a claim on file for West Kendall is what I'm saying.
[AGENT][NEUTRAL] So they can still file the claim.
[CUSTOMER][NEUTRAL] I see, so who has to.
[CUSTOMER][NEUTRAL] OK, so I have to call back Cigna to have them reissue a claim to you?
[AGENT][NEUTRAL] Uh, Cigna doesn't, so they send it to Sigma, I'm sorry, Sigma. They send it to Cigna and then Cigna will send them back the explanation of benefits and everything, and then West Kindle sends it to us. So they sent it to Cigna, but they didn't send it to your secondary.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] I see. So then, um, I have to get in contact with West Kendal Baptist to let them know to, uh, send the claim to APL.
[AGENT][NEUTRAL] Right, and there's no um like deadline to file a claim with us as long as the policy was active on that day and it was, so they can file the claim, they still have time to do that.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm, um, OK, let me then give them a call.
[CUSTOMER][POSITIVE] And see what's going on. Thank you.
[AGENT][POSITIVE] You're very welcome, Mrs. [PII]. Was there anything else I could assist you with today?
[CUSTOMER][POSITIVE] No, that was it. Thank you.
[AGENT][POSITIVE] You're welcome. Well, thanks for calling APL. I hope you have a great weekend.
[CUSTOMER][POSITIVE] Thank you. You too.
[AGENT][POSITIVE] Thank you. Bye-bye.
[CUSTOMER][NEUTRAL] Alright bye bye.