AccountId: 011433970860
ContactId: d80cda48-eacd-42ed-bc01-dfc10caa7fab
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 719039 ms
Total Talk Time (AGENT): 235081 ms
Total Talk Time (CUSTOMER): 374733 ms
Interruptions: 3
Overall Sentiment: AGENT=0.7, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/13/d80cda48-eacd-42ed-bc01-dfc10caa7fab_20250513T21:59_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yes, uh, my name is [PII]. I have a policy with you all. Let me give you my, uh, I guess you want a group number?
[AGENT][NEUTRAL] Um, or do you have your policy number?
[CUSTOMER][NEUTRAL] Let yeah, OK, here it is um.
[CUSTOMER][NEUTRAL] It's regard regarding to an outpatient benefit uh.
[CUSTOMER][NEUTRAL] 01986454
[CUSTOMER][NEUTRAL] M as in Minnesota. L as in Louisiana, number 8.
[AGENT][NEUTRAL] OK, thank you, Mr. [PII]. Can I
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Can I get your birth date, please?
[CUSTOMER][NEUTRAL] Yeah, I
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And do you have a good callback number in case we are disconnected?
[CUSTOMER][NEUTRAL] Sure [PII].
[AGENT][NEUTRAL] OK, just need two other pieces of information, your address and your email address.
[CUSTOMER][NEUTRAL] Sure, [PII]. Email [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And you were checking on a claim for yourself?
[CUSTOMER][NEUTRAL] I sent uh a.
[CUSTOMER][NEUTRAL] I, I sent two claim, uh, requests last week and I just wanna make sure you got them. I sent them by to your fax number.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] OK, was it for, uh, it looks like we received these claims recently for dates of service in [PII]?
[AGENT][NEUTRAL] Is that right? OK, looks like there was um.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Well, I think one is [PII] and the other 1 [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, let me see what's going on.
[AGENT][NEUTRAL] OK, it looks like there were several charges submitted, um, some are for office visits and then some were for procedures and office visits. Is that correct?
[CUSTOMER][NEUTRAL] Well, it's just there's a variety of things, but uh since that's what they give me, you know, at the, at the hospital, so I, I basically marked.
[CUSTOMER][NEUTRAL] The big, uh, the incident.
[CUSTOMER][NEUTRAL] Of the major incident which was their, you know, surgeries.
[AGENT][NEUTRAL] OK. Um, let me pull up your policy, because it looks like they were all non-covered due to your policy, but let me pull your policy up real quick.
[AGENT][NEUTRAL] There is one charge on there.
[AGENT][NEUTRAL] Let's see, um, for, uh, let's see, fine.
[CUSTOMER][NEUTRAL] Both of them are like over $50,000.
[CUSTOMER][NEUTRAL] Well, actually one was, uh, was, was actually a hip hip surgeon that where the surgeon charged uh 5 or 6000, but the total cost is more than that because you have to.
[CUSTOMER][NEUTRAL] You know there's other for what but basically let's let's talk about the policy. The policy.
[CUSTOMER][NEGATIVE] It's supposed to cover whatever if I if I met my pre my my uh deductible and I'm going out of pocket, correct?
[AGENT][NEUTRAL] So it covers certain things. Um, so, for instance, if, if something is performed in the doctor's office and the doctor's office visit itself, those are not covered under the policy.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah, this was not done in a doctor's office or surgery centers.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] OK, um, let me see.
[CUSTOMER][NEUTRAL] So that's why you see it's hard to get from a hospital or outpatient surgery center something specific about that particular day they just send you the whole record so that's why I marked it in and there's several, there's several uh.
[CUSTOMER][NEUTRAL] Sheets of paper in the email and then marked on the on the side is the incident itself.
[AGENT][NEUTRAL] OK, um, it looks like, let's see.
[AGENT][NEUTRAL] So I'm pulling up what we received. So we received.
[CUSTOMER][NEUTRAL] So our surgeries are covered, right?
[AGENT][NEUTRAL] So outpatient hospital services are covered, correct.
[AGENT][NEUTRAL] Um, so surgery performed in an outpatient hospital.
[CUSTOMER][NEUTRAL] OK, both of, both of them or that?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] So you submitted a claim for but go ahead.
[CUSTOMER][NEUTRAL] Those
[CUSTOMER][NEUTRAL] Yes, [PII] and one I think for.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] It was a um.
[CUSTOMER][NEUTRAL] Orthopedic, uh, it was for the hip surgery.
[AGENT][NEUTRAL] OK, so the [PII] Hospital.
[CUSTOMER][NEUTRAL] It was actually 2 of that year, but I, I, I, my, it was like a 20 page report.
[CUSTOMER][NEUTRAL] Actually, but I know you have a limit of 2000, so I've actually had cardiovascular surgery and 22, but I sent you the, the one, not even one I sent you the other one, so which was my the kidney stone, kidney stone at [PII], that's [PII] and the other one,
[CUSTOMER][NEUTRAL] I think it was actually oh yeah Memorial Hospital.
[CUSTOMER][NEUTRAL] Uh, outpatient for the hip surgery for 23.
[AGENT][NEUTRAL] OK, so the one.
[CUSTOMER][NEUTRAL] [PII] was uh.
[AGENT][NEUTRAL] Um, so the
[CUSTOMER][NEUTRAL] The [PII] one is the is the kidney stone surgery?
[CUSTOMER][NEUTRAL] And then the other one's a hip surgery at Memorial.
[AGENT][NEUTRAL] OK, so the one for [PII], I do see that one, and we need your primary explanation of benefits showing how they processed and paid the claim.
[AGENT][NEUTRAL] So that's what we need for that.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then we received several other pages, um, so it was for Doctor, um, Doctor [PII].
[AGENT][NEUTRAL] So all of these are saying you're in the doctor's office.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Um, so if, if they're not, we need.
[CUSTOMER][NEUTRAL] No, it's an outpatient. Oh no, forget about the office visits. That's why I say in particular there's I not highlighted but marked the line item for the hip surgery when charged like $5000 or $6000.
[AGENT][NEUTRAL] OK, it, but it doesn't indicate where the.
[CUSTOMER][NEUTRAL] For the surgery.
[AGENT][NEUTRAL] Right, so we need to know where the place of service is. I do see that. I see 712 2023 total hip arthroplasty. I see that for Doctor [PII] for $5000.
[CUSTOMER][NEUTRAL] Where was it? Look at the heading uh at the at the heading of the, it says Memorial Hospital at the top of the the first page.
[CUSTOMER][NEUTRAL] Cypress Creek.
[AGENT][NEUTRAL] Um, this says Memorial physician group.
[AGENT][NEUTRAL] So I'm not sure.
[CUSTOMER][NEUTRAL] Really? OK, well then.
[CUSTOMER][NEUTRAL] No, it's actually an outpatient clinic. All they do is surgeries there on Cyprus. That's where he does the surgery, Cypress [PII] in uh.
[CUSTOMER][NEUTRAL] In [PII].
[AGENT][NEUTRAL] OK, so
[CUSTOMER][NEUTRAL] But I can clear that up. So tell me, said something about explanation of benefits you want what my insurance policy, what it was covering, is that what you're saying?
[AGENT][NEUTRAL] Yes, we need your explanation of benefits from Blue Cross Blue Shield.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So if you'll, if you eat
[CUSTOMER][NEUTRAL] I have that actually.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So I'll just follow up with that, but is there a way now to just follow up with an email instead of faxing?
[AGENT][NEUTRAL] Um, no, we only accept fax. It's the only secured portal. Our email is not secure, so.
[CUSTOMER][NEUTRAL] Oh my [PII], wait.
[CUSTOMER][NEUTRAL] Are antiquated. OK, I will follow up with explanation of benefits and then, uh, something showing, well, tell me what about the Bethesda? How does that one look?
[AGENT][NEUTRAL] Um, so, so all of the rest of the charges besides the hospital charges for, uh, let me pull it up again, which one you submitted.
[AGENT][NEUTRAL] Besides Bethesda Hospital.
[CUSTOMER][NEUTRAL] You know what you're gonna.
[CUSTOMER][NEUTRAL] Yes, go ahead, go ahead.
[AGENT][NEUTRAL] Besides Bethesda Hospital, which for that one we need your primary explanation of benefits, all of the other services that you submitted indicate that this was done in a doctor's office. So we're gonna need documentation showing that it was done in an outpatient facility and not the actual doctor's office to be considered along with.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Your primary explanation of benefits.
[CUSTOMER][NEUTRAL] OK, you know what, for that year, since you all have a limit of $2000 I'm actually gonna send you the, the other surgery which was like what $90,000 and uh, that would clear that one up, uh, I'm, I'm, I'm gonna get I think it just substituted because they're directly from the hospital and I was actually in the hospital for about 7 days, OK, so.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. Well, that one would be your inpatient.
[CUSTOMER][NEUTRAL] Uh, that, and, but I didn't have it with me. I didn't have it with me. I thought there would be an issue with this, but I will just submit, resubmit for [PII] and [PII].
[CUSTOMER][NEUTRAL] Something showing that it was actually an outpatient surgery center, correct?
[AGENT][NEUTRAL] Yes, we need to show that that was the place of service, correct.
[CUSTOMER][NEUTRAL] Plus the benefits of.
[CUSTOMER][NEUTRAL] OK, but tell me, so I don't know have a copy of the policy itself. Maybe I must have, uh, but what is it that you're looking to give in order to cover it? What are you looking for?
[AGENT][NEUTRAL] So the place of service has to be rendered in an outpatient hospital setting?
[AGENT][NEUTRAL] Cause, cause you have 2 benefits on your, you have 2 benefits on your policy. You have inpatient.
[CUSTOMER][POSITIVE] Not a problem.
[AGENT][NEUTRAL] Um, and this is not a guarantee of payment, it's a basic outline of your policy. You have an inpatient benefit that pays $2000 per calendar year, and that's for inpatient hospital benefits. And then you have a separate $2000 benefit for outpatient hospital services. So it's, it's gonna have to be for
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] OK, so, so it can be a total of 4000 then right per year?
[AGENT][POSITIVE] Correct, yes.
[CUSTOMER][NEUTRAL] OK, well then that then we need to fix this because.
[CUSTOMER][NEUTRAL] I, I will send them an additional one for [PII], you see, early forget what, what, when it was April, the surgery for the kidney stone that was.
[CUSTOMER][NEUTRAL] Outpatient
[CUSTOMER][NEUTRAL] And then the one for uh inpatient uh in [PII], then the 23 I understand what you wanna know so I'm gonna follow up. I just wanna make sure you got that.
[CUSTOMER][NEUTRAL] Sent to the same fax.
[CUSTOMER][NEUTRAL] And uh and showing that it is an actually outpatient surgery center on the [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK. Anything else I can help with, sir?
[CUSTOMER][POSITIVE] That's all thanks a lot. I appreciate it. Where, where are you asking from?
[AGENT][POSITIVE] Exactly
[AGENT][NEUTRAL] Um, I'm in [PII], [PII].
[CUSTOMER][NEUTRAL] Where?
[CUSTOMER][POSITIVE] [PII]. OK. Sounds like your accent sounds lik[PII], uh, like many of the people I met from [PII], so I figured it was a really nice friendly people there. I I always like.
[AGENT][POSITIVE] Good, that's good to hear. Thank you so much.
[CUSTOMER][POSITIVE] It's a nice accent.
[CUSTOMER][POSITIVE] All right, thank you.
[AGENT][POSITIVE] All right, thanks for calling APL. I hope you have a good evening.
[CUSTOMER][NEUTRAL] You too bye.
[AGENT][POSITIVE] Thank you, bye bye.