AccountId: 011433970860
ContactId: d40c9ec8-a0e1-4b57-92a7-5b3c4d135b56
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1087800 ms
Total Talk Time (AGENT): 358356 ms
Total Talk Time (CUSTOMER): 465219 ms
Interruptions: 2
Overall Sentiment: AGENT=0.3, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/08/d40c9ec8-a0e1-4b57-92a7-5b3c4d135b56_20250508T18:28_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, yes, uh, my name is [PII], and, um, I have a policy with you guys and I'm just following up on a couple of claims, um, one that I've had pending for a while, um, just wanted to follow up on that, and one that's a little bit more recent, um, that I didn't see, um, a full payout on. I just wanted to call and see if I did something wrong or if there's a reason why, um, well let me know what you need to pull me pull my account up.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, sure, [PII]. I can help you with claim status. Do you have a policy number?
[CUSTOMER][NEUTRAL] Uh, let's see, where is which one is that on the card? Is it the group number or payer ID?
[AGENT][NEUTRAL] Uh, it'd be the policy certificate number.
[AGENT][NEUTRAL] Uh, should be in the bottom left, I believe.
[CUSTOMER][NEUTRAL] Oh, OK, um.
[CUSTOMER][NEUTRAL] It's the, the like the in-hospital or outpatient?
[AGENT][NEUTRAL] Yeah, either number, the numbers should be the same on each. I just need the numbers.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] You know, they're actually different by one by one digit. Um, so it's the inhospital benefit number is 023.
[CUSTOMER][NEUTRAL] 173
[CUSTOMER][NEUTRAL] 08 M as in Mary, L as in Larry 7
[AGENT][NEUTRAL] And were those claims for yourself?
[CUSTOMER][NEUTRAL] Um, one is for my daughter, the other is for my son actually.
[AGENT][NEUTRAL] And can I verify your date of birth?
[CUSTOMER][NEUTRAL] Uh, mine is [PII].
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] And do you have a good callback number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yes, it's [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And then just need your address and an email address.
[CUSTOMER][NEUTRAL] Sure, it's [PII], and email address is [PII].
[AGENT][NEUTRAL] Uh, I think I'm, we might have a work email.
[CUSTOMER][NEUTRAL] Oh, you probably have my work one, yeah, it's uh [PII].
[AGENT][NEUTRAL] OK, do you want to keep that email the same, the work email?
[CUSTOMER][NEUTRAL] Um, it doesn't really matter. Yeah, that's fine.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and you said we were looking at a claim for your daughter, is that right?
[CUSTOMER][NEUTRAL] Yeah, well, let's start with my son. Um, so his name is [PII], and his date of birth is uh [PII].
[CUSTOMER][NEUTRAL] And the claim date is let me look that up here.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] This is for a procedure he had done on um [PII] of last year.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Are we checking on like the hospital claim or a different one? Um, I have a hospital claim and an anesthesia claim.
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] OK, so, um, so yeah, so basically the, the claims were all paid out, um, as far as like what my EOB shows, um, but it was my understanding that with outpatient procedures that um it doesn't really matter even how much I paid out of pocket that it is a $500 maximum benefit for outpatient procedures is that accurate?
[AGENT][NEUTRAL] Um, it, it will pay up to 500, so it's not gonna pay more than what your primary leftover.
[AGENT][NEUTRAL] So yeah, if they only left like for if the example they left a balance of 200 we'll only pay 200 we're not gonna pay more than that.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][POSITIVE] I got you.
[CUSTOMER][NEUTRAL] OK, yeah, I, that was just a miscommunication on our, our broker's part then on how that's paid out.
[AGENT][POSITIVE] Sorry about that.
[CUSTOMER][NEUTRAL] That's no problem. That's OK, um, and so the second one, relates to a long standing issue I've had, and I've called a couple times, um, over the years on it, but never really got any kind of um conclusive final confirmation or follow up um it's for my daughter [PII] and let me see that original date it was probably [PII].
[CUSTOMER][NEUTRAL] Um, let me see, and it would have been a [PII].
[AGENT][NEUTRAL] OK. Uh, let me get that pulled up.
[CUSTOMER][NEUTRAL] I've got
[CUSTOMER][NEUTRAL] I don't know, maybe it was the, maybe it was the [PII].
[CUSTOMER][NEUTRAL] Yeah, I think it might have been [PII].
[AGENT][NEUTRAL] [PII], OK.
[AGENT][NEUTRAL] OK. And this, is this for like physician charges inpatient or?
[CUSTOMER][NEUTRAL] Um, so basically I had received a bill from the hospital, um, but I've given them the, uh, the APL card when I was there, and, um, I'm trying to think of how, how it all went down, yeah, I've given them the card, um, and then.
[CUSTOMER][NEUTRAL] Uh let me think, um.
[CUSTOMER][NEUTRAL] So you guys had paid out um $4800 to them um and I think that was the yeah that was the total bill like before it processed, um.
[CUSTOMER][NEUTRAL] Like through my primary insurance?
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Um, and you guys have paid out the $4800 and then I, and then I received a bill from them that the total my total cost, you know, out of pocket was gonna be $1000 so you guys were basically requesting a refund from them. I, I don't know the status of that, um, but because.
[CUSTOMER][NEGATIVE] Because you paid out the full amount to them, um, I had other claims that I had processed for Harlow, and they didn't go through bec[PII] my maximum benefit had been reached, even though you guys should not have paid out that $4800.
[CUSTOMER][NEUTRAL] Does that make sense? Sorry, this is obviously a couple of years ago now, so I'm trying to jog my memory and actually how it all went down, but that is certainly close to the sum of it.
[AGENT][NEUTRAL] OK, uh, let me see.
[AGENT][NEUTRAL] Let me see if I have any notes.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Yeah, I see where we paid um.
[AGENT][NEUTRAL] I'm reading the notes, give me one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I, I do see the claim for 10.
[AGENT][NEUTRAL] Well, it's, let's see.
[AGENT][NEUTRAL] You claimed for 10:30 and 10:31 where we paid.
[AGENT][NEUTRAL] $100 for each charge. It was for Doctor uh [PII] or [PII].
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] This is for inpatient services.
[AGENT][NEUTRAL] And then, let's see, let me pull up your policy and see.
[AGENT][NEUTRAL] OK, let's see what we have.
[AGENT][NEUTRAL] OK, so your inpatient benefit, um, that pays $5000 per covered person. I see that.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so you're saying there was a $4800 payment that we paid to the provider and then you said you're informed we requested a refund?
[CUSTOMER][NEUTRAL] Um, so essentially, um, they must have contacted you guys and said that, you know, the bill is for $4800 so, um, you guys have paid that out, but they hadn't processed it through my primary insurance yet. You guys are normally pretty good about waiting to receive an EOB to see what process and you know what the total cost ends up being, and the bill was originally for $4800 and that's what you guys had paid.
[AGENT][NEUTRAL] I
[CUSTOMER][NEGATIVE] And when I got my bill from them, it was for $1000. So when I went back to look at what you guys paid them, I saw the $4800 and I was like, wait a minute, that's not right. So I called you guys and and let you know, you know, to request a refund from them, um.
[CUSTOMER][NEUTRAL] Because you would pay that out in error, um, and I would, I mean, even if it doesn't really directly apply to me, and even if I didn't have any further claims that that's money that you guys should have and not the, not the hospital. So,
[CUSTOMER][POSITIVE] I felt like that was, you know, the right thing to do. Um, so, yeah, and I, like I said, I called a couple times to basically, you know, let the rep know and, and it's, it always seems like it's processing, but when I revisited it today, I'm like, all right, now it's been almost 2 years, like, there's got to be some resolution on this.
[AGENT][NEUTRAL] Yeah, it looks like let me see, um.
[AGENT][NEUTRAL] I see where we
[AGENT][NEUTRAL] Refunded the 3800 and then we just paid 1000. So that looks like that's all that we've paid is the 1000.
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] OK, so you did somehow get a refund from them.
[AGENT][NEUTRAL] Yeah, it appears that we did because we just, yeah, this shows that that's just that payout of 1000.
[CUSTOMER][NEUTRAL] At least that's how it appears, OK.
[AGENT][NEUTRAL] So, um,
[CUSTOMER][NEUTRAL] OK, well that's, that's good um so I know I processed um.
[AGENT][NEUTRAL] Yeah, it looks like that's been.
[CUSTOMER][NEUTRAL] I think I had processed two claims after that. I know definitely one, and that was for Dr. [PII], I think it was, and that was for $100. Um, and then I think there was a [PII] one for $85. Now both of those were denied because it had showed that my maximum payout of the $5000 had been met, when in actuality, technically was not. Um, so,
[AGENT][NEUTRAL] OK, you know what dates those were?
[CUSTOMER][NEUTRAL] I don't know what what what to do about that.
[CUSTOMER][NEUTRAL] Say it again.
[AGENT][NEUTRAL] Uh, do you know what dates those were for those providers?
[CUSTOMER][NEUTRAL] Like the date of the date of service or the date that I submitted.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] I, I see one for Doctor [PII]. Let me see. So, so the
[CUSTOMER][NEUTRAL] And it's for 100?
[AGENT][NEUTRAL] Uh, this one's for 678. It's for 1029 23.
[AGENT][NEGATIVE] Let me see why it denied.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] Duplicate, let me find the original.
[CUSTOMER][NEUTRAL] 18
[AGENT][NEUTRAL] Uh, let's see, 1029, 23.
[AGENT][NEUTRAL] OK, let's see
[AGENT][POSITIVE] OK, yeah, and just to clarify, yes, we, we definitely did get a refund so that that part's resolved, um.
[CUSTOMER][POSITIVE] OK, well that's good.
[AGENT][NEUTRAL] OK, so 1029, 23. This is Doctor [PII]. Let me see.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Emergency
[AGENT][NEUTRAL] And yeah, this looks like an emergency, so that'd be under.
[CUSTOMER][NEUTRAL] Here it is.
[AGENT][POSITIVE] An outpatient benefit.
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] I can't figure out which, OK, let's see.
[AGENT][NEUTRAL] 339-927.
[AGENT][NEUTRAL] 339.
[AGENT][NEUTRAL] So it looks like what we did was we lumped, OK, let me look at your outpatient benefit.
[AGENT][NEUTRAL] Uh, let's see.
[AGENT][NEUTRAL] OK, so for your outpatient benefit, it's, so what it does is it pays a maximum of 500 per calendar day.
[AGENT][NEUTRAL] And so any services for the data service 1023, which included Dr. [PII], um, we just paid a lump sum of $500 and the claim that we received for that, it looks like we've got Dr. [PII]'s charges on there, and Mariana Doll, um, so we, we did pay a $500 for that calendar day benefit.
[AGENT][NEUTRAL] And that was on.
[AGENT][NEUTRAL] Uh, that was on.
[AGENT][NEUTRAL] It was by direct deposit [PII]. So for specifically for 1029 we paid out the full $500 benefit. So there may have been charges in excess of that, but the benefit is $500 per day. So that's the maximum we pay for outpatient services in one day.
[CUSTOMER][NEUTRAL] But now this, she was inpatient, so that's why I'm confused. It, it wasn't classified as that?
[AGENT][NEUTRAL] Um, let's see.
[AGENT][NEUTRAL] Well, they billed it as outpatient, so
[AGENT][NEUTRAL] It's, it's based on how they build the services as well, so it's if they build like a place of service that shows.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] Right, right.
[AGENT][NEUTRAL] Um, was she, did she come to the emergency room first and then she was admitted? Is that what happened?
[CUSTOMER][NEUTRAL] Yeah, yeah.
[AGENT][NEUTRAL] OK, yeah, so, so when they
[CUSTOMER][NEUTRAL] You know, she was a newborn. She had a fever, so they wanted her, they wanted her to stay overnight.
[AGENT][NEUTRAL] When they build that they indicated that it was outpatient so they would have to rebuild.
[CUSTOMER][NEUTRAL] Now if she stays overnight I assume that would not be outpatient correct?
[AGENT][NEUTRAL] Yes, but it's based on how they send the bill to us and so the bill that they sent to us, like the claim, yeah, indicated outpatient. Now if they sent a corrected claim.
[CUSTOMER][NEUTRAL] Yeah, yeah, no, I understand that.
[AGENT][NEUTRAL] Um, that indicated it was an inpatient stay, then that could potentially um change, but
[AGENT][NEUTRAL] Um, under the outpatient benefits is hospital emergency room. So,
[AGENT][NEUTRAL] You know, you can't, you can't usually, you can't stay inpatient in an emergency room cause they'll just admit you to the hospital. So, you know, it's also based on the fact that it was emergency room services that also, you know, made how it paid out the 500 because it was emergency room.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Does that make sense?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, it does, um, and I again because it was so long ago I don't remember all the specifics around it but.
[CUSTOMER][NEUTRAL] And and I've dealt with other reps, um, and I, I never really felt like they were explaining it the way you are so um I just wanna make sure that I essentially just wanted to make sure everything was processed correctly but sounds like as far as what you're seeing, everything looks like it was finally corrected and and it looks like it was paid out correctly according to what they, you know, how they sent it to you guys and how it was processed.
[AGENT][NEUTRAL] That's correct, yes, from what I'm seeing how they build us data service, we got the refund. It looks like everything, um, is corrected or, you know, been correctly processed. Sorry, it's been so confusing. I definitely.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. OK.
[CUSTOMER][NEUTRAL] Yeah, I mean as far as uh.
[AGENT][NEUTRAL] Yeah, sorry about that. I'm sorry about that. Yeah, we don't, we don't want it to be confusing, but unfortunately, sometimes these things are so.
[CUSTOMER][NEUTRAL] Say it again.
[CUSTOMER][NEUTRAL] Yeah, and that's OK. And I, I had, I had twins at the time, and both of them ended up having an emergency visit with this, this fever. So obviously, I was, it was, uh, it was just kind of crazy. Um, so dealing with this later was like, there was just, you know, and there's a lot of codes and you're dealing with lots of different people, and it's just like it's, it becomes cumbersome, but I just wanted to make sure everything was eventually processed correctly. So it sounds like it was.
[AGENT][NEUTRAL] Oh gosh.
[AGENT][POSITIVE] Yeah, definitely.
[AGENT][NEUTRAL] Oh gosh, yeah.
[AGENT][NEUTRAL] OK. Is there anything else I can help with today, Ms. [PII]?
[CUSTOMER][POSITIVE] No, thank you for your assistance. I appreciate it.
[AGENT][POSITIVE] OK, well, thank you for calling APL. I hope you have a good afternoon.
[CUSTOMER][POSITIVE] Thank you. You too.
[AGENT][POSITIVE] Thank you. Bye-bye.
[CUSTOMER][NEUTRAL] Bye bye.