AccountId: 011433970860
ContactId: d33d9489-da99-4540-aacc-993165dfb396
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 722219 ms
Total Talk Time (AGENT): 328843 ms
Total Talk Time (CUSTOMER): 295621 ms
Interruptions: 2
Overall Sentiment: AGENT=0.6, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/21/d33d9489-da99-4540-aacc-993165dfb396_20250421T17:20_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, I just have some questions on um a claim uh that I had sent over and I got a um information back with a check and I'm just not kind of sure what's going on. Could you look it up for me to see what's going on with this?
[AGENT][POSITIVE] Sure. OK, I can definitely help you with your claim.
[CUSTOMER][NEUTRAL] OK, you need like
[AGENT][NEUTRAL] May I have your name and
[CUSTOMER][NEUTRAL] OK. Do you need my policy? Yeah, it's [PII].
[CUSTOMER][NEUTRAL] And you want the policy number?
[AGENT][NEUTRAL] Well, 1st may I have a good contact number in case we're disconnected and then the policy number.
[CUSTOMER][NEUTRAL] Sure, it's 773-213.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] 6386
[AGENT][NEUTRAL] And the policy number whenever you're ready.
[CUSTOMER][NEUTRAL] 02396205
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] Wait,
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And can you verify your date of birth, your mailing and email address on file?
[CUSTOMER][NEUTRAL] Date of birth is [PII]. Um, address, you said?
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Email address or just regular? OK, is [PII] OK [PII] and then address is [PII].
[AGENT][NEUTRAL] Both.
[AGENT][NEUTRAL] OK, this 1 may be an old address and it's in [PII].
[CUSTOMER][NEUTRAL] Is it [PII]? Yeah, [PII] [PII]. So that was the address that we had when we had the insurance through you guys, but since then we've moved.
[AGENT][NEUTRAL] You want me to update this for you?
[CUSTOMER][NEUTRAL] Yes, please.
[AGENT][NEUTRAL] Uh.
[AGENT][NEUTRAL] OK, and then can you repeat the new one and I'll switch it for you?
[CUSTOMER][NEUTRAL] Yeah, it's [PII].
[CUSTOMER][NEUTRAL] [PII], it's [PII].
[CUSTOMER][NEUTRAL] And it's [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Is it like [PII] or is it all together?
[CUSTOMER][NEUTRAL] Yeah, I think it was [PII].
[AGENT][NEUTRAL] [PII], OK. And then your zip code?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, hold on one moment let me save this.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] Alright, so I've updated the address for you and all the information provided is a verification of benefits, not a guarantee of payment. So let me take a look at this claim. Was it all for the same reason? You said you received a check?
[CUSTOMER][NEUTRAL] Yeah, so I sent a bunch of um paperwork over because they said they needed more information about um.
[CUSTOMER][NEUTRAL] Uh, some of the claims that we had like from the providers with like codes and stuff so that all that was sent. I'm assuming I don't know if it was all sent over yet or or I sent a bunch of stuff over. Then they sent me a letter saying that they received the claim and they're working on it but then like last week I got.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] It has explanation of benefits and it has like stuff on it and then has a check written out to us so I'm, I'm just kind of confused as to what's going on.
[AGENT][NEUTRAL] OK, wait a minute. So what, um, let me look at this first.
[AGENT][NEUTRAL] Is the claim for you or one of your dependents or a spouse?
[CUSTOMER][NEUTRAL] Um, sure, so the, this one, the check, this, this explanation that was sent, it has me, my name, [PII], insured, the claimant is my husband, who's my spouse who is also on the policy.
[AGENT][NEUTRAL] Oh, OK, let me look under him. I'm like, I don't see anything here. OK, hold on one second.
[CUSTOMER][NEUTRAL] Yeah. Yeah.
[CUSTOMER][NEUTRAL] OK. OK.
[CUSTOMER][POSITIVE] No problem.
[AGENT][NEUTRAL] OK, here we go.
[AGENT][NEUTRAL] OK, so I'm in the right place now. OK, so I see the check, right, and then what's going on? There's some that were
[AGENT][NEUTRAL] Looks like it's like one.
[AGENT][NEGATIVE] A few that were denied.
[AGENT][NEUTRAL] Is that what
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] You're trying to, well, what's the question?
[CUSTOMER][NEUTRAL] Um, well, I just, yeah, I just don't know because I, I sent a bunch of stuff over. I thought it was for, I don't know if it was all for my husband. This, so like.
[CUSTOMER][NEUTRAL] Uh, I don't know. I'm just really confused because there there's a lot here and I sent a bunch of stuff over so now I, now this check was, was written out to me. So does that mean?
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Like it normally doesn't like, don't, don't they pay the, the hospitals or like don't pay them directly? Like, why is the check coming back to me, shouldn't have gotten paid to.
[AGENT][NEUTRAL] The provider
[CUSTOMER][NEUTRAL] The hospital or other bills that was, yeah.
[AGENT][NEUTRAL] OK. So, let me take a look at the claim. We, what is this, hospital admission.
[AGENT][NEUTRAL] So because, so there's two things. So now if the provider has filed this claim, it could, if something was owed to them, it possibly could have went to them, but because you filed the claim, the benefits came to you. If there is something owed to the provider, it can be taken out of this $1,325 that's um being sent to you, and then, you know, you can pay them. But the other of the, of what was submitted for filing.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The ones that were denied, um, like there's a few on here that the um policy doesn't pay like um.
[AGENT][NEUTRAL] How can I explain it? Because it's no impatient.
[CUSTOMER][NEUTRAL] Like
[AGENT][NEUTRAL] If the, if, um, because some of these charges were from the doctor through inpatient, that's why it wasn't.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Approved. So that's a lot of 123, these 3 facility charges on here. I see that the no reason the policy provides no benefits for charges made by a doctor for inpatient. And then you have some, let me see what this one means.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The policy doesn't provide benefits for diagnostic testing. So the the ones that were not paid out on.
[AGENT][NEUTRAL] Which is, it's a total of 5 there because it is not covered on the policy, it's not covered when a doctor um performs it because of the policy and then there's 1 more here.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 5201.
[AGENT][NEUTRAL] Oh, OK, so it's saying the hospital um confinement couldn't be paid because it had paid out the $750 for the hospital admission.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And it's on the same day, so they paid when that was the most, which was the $750.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, OK, so the ones that like, so I'm looking at the claims, so the ones like at the top where it says non-covered, so those are the ones do you, do you, so was anything paid to be to the providers in addition or besides this just this check to me like how do I know what if what I still owe them or whatever? No, so nothing else is paid.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] So, if something, right, so moving forward like if something was paid to you and the provider on the explanation of benefits, it'll say like paid to patient, blah blah blah, paid to provider blah blah blah, but for this one, everything was paid to you. There was nothing paid to the provider.
[CUSTOMER][NEUTRAL] OK, so this page. OK, um, so, um, does yours like show like the ones that it says like not covered, does it show the amount there now I'm just curious of like how much I'm still gonna owe these providers like it just say, does it say like for the first one that is um.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Non-covered procedure for that has has the the procedure I guess it's called FAC like does it show like the amount or I'm just curious as to how much extra out of all that was not covered.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] Sure, hold on one second, let me see if I can see the charged.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Is this your only insurance?
[CUSTOMER][NEUTRAL] Yeah, at the time, I mean, we have different insurance now, but this is, yeah, my husband was like self-employed, so we, and of course, within the few months that we had this insurance, he ended up having to go to the hospital. So I'm just trying to figure out.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Budget. Mhm.
[CUSTOMER][NEUTRAL] It's like a lot of money that, you know, we still owe out of pocket, yeah.
[AGENT][NEUTRAL] No, the only reason I was asking is because sometimes the the um like doctor's office or the hospital, they'll send like just what's left over or something like that. So I wasn't sure if this is really the true balance for this or if this is just like, OK, but let me, I'm just gonna add it up. Hold on one second.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Because
[AGENT][NEUTRAL] OK, plus.
[AGENT][NEUTRAL] OK, so of all the denied codes, the total is $35,175.80 but that the best thing to do would be to reach out to the provider and see what the outstanding balance or if you have an outstanding balance and go from there because I don't know, they could adjust this, they could take, you know, there's different options, so that's just from me adding up the codes that weren't paid.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] Um, and this is just showing under him because I think there was some.
[CUSTOMER][NEUTRAL] Bills that were sent, but you said nothing came up from my name, right?
[AGENT][NEUTRAL] Well, it
[CUSTOMER][NEUTRAL] When you, when you looked
[AGENT][NEUTRAL] Nothing recent, um, but if it's, let me see.
[CUSTOMER][NEUTRAL] Like
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] The last claim we processed for you, we received, OK, it's [PII].
[CUSTOMER][NEUTRAL] Well.
[CUSTOMER][NEUTRAL] That's all, yeah.
[AGENT][NEUTRAL] But that's the only, that's the only one I see for you.
[CUSTOMER][NEUTRAL] Um, OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. OK, so basically.
[CUSTOMER][NEGATIVE] With everything I sent over this was sent back the stuff that they're able to pay was just made to me and then I'm assumed to put that towards my balance of with the provider and then the rest of the stuff that large amount pretty much was not covered, um.
[CUSTOMER][NEGATIVE] So basically, we, we did not have very, very, very good coverage for hospitalization is what it comes down to for because it's a big amount.
[AGENT][NEUTRAL] Big number. So the hospital indemnity policies are limited medical benefits. So, but I still, that is a big number, but I still want you to see if it's if it's correct and what the options are.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Because they could very well adjust it, write some off, um, well, there's a few different options that they could offer, but every provider is different, so I don't want to say one and they don't offer it.
[CUSTOMER][NEUTRAL] Yeah, OK, all right, I will.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Right, right, right, yeah, to just check with them then, OK.
[CUSTOMER][POSITIVE] Sounds good. All right, well, thank you for your help. I appreciate it.
[AGENT][POSITIVE] You're very welcome, Mrs. [PII]. Was there anything else I can help you with today?
[CUSTOMER][NEUTRAL] I think that's it.
[AGENT][POSITIVE] All right, well, thank you so much for calling APL. I hope you have a good day.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thanks. You too. Bye-bye.
[AGENT][POSITIVE] Thank you. Bye bye.