AccountId: 011433970860
ContactId: dcc62951-475e-465e-b0ee-e76cc183809d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 982280 ms
Total Talk Time (AGENT): 340195 ms
Total Talk Time (CUSTOMER): 312008 ms
Interruptions: 2
Overall Sentiment: AGENT=0.4, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/29/dcc62951-475e-465e-b0ee-e76cc183809d_20250429T13:57_UTC.wav
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[AGENT][NEUTRAL] APL, my name is [PII]. How can I assist you today?
[CUSTOMER][NEUTRAL] Good Morning [PII]. My name is [PII]. How are you?
[AGENT][POSITIVE] I'm good how are you?
[CUSTOMER][POSITIVE] I'm doing well thank you.
[CUSTOMER][NEUTRAL] So I'm an agent calling today um, one of my clients uh that's been terminated um from an employee that's been terminated is trying to file a claim, but he's been having issues so I'm trying to see if we can.
[CUSTOMER][NEUTRAL] Look into it to see what's going on.
[AGENT][POSITIVE] OK, I'll be happy to assist, um, one moment, let's see.
[AGENT][NEUTRAL] And do you have that policy number?
[CUSTOMER][NEUTRAL] Oh, I have the, the group number which is 19993.
[AGENT][NEUTRAL] OK, um, what's the patient's name?
[CUSTOMER][NEUTRAL] Patient's name is [PII].
[CUSTOMER][POSITIVE] [PII]
[CUSTOMER][NEUTRAL] I don't have like his member info being that he's been termed so I can't look it up on the site at least I don't think I can.
[CUSTOMER][NEUTRAL] But I have all his personal info.
[AGENT][NEUTRAL] [PII], OK.
[AGENT][NEUTRAL] Do you have an address?
[CUSTOMER][NEUTRAL] Yes, I do. Address is [PII].
[AGENT][NEUTRAL] And date of birth.
[CUSTOMER][NEUTRAL] Date of birth is.
[CUSTOMER][NEUTRAL] Uh, [PII].
[AGENT][NEUTRAL] Thank you for that. Alright, so what problem is he having with filing the claim?
[CUSTOMER][NEUTRAL] So, um, basically he's, uh, he had a claim on [PII], which was his last day of coverage of [PII], and it was, um, an outpatient facility. He says he calls them every time and gives them the APL info and then they say that they send it and then he just continues to get bills.
[AGENT][NEUTRAL] You said his coverage ended with us in [PII]?
[CUSTOMER][NEUTRAL] [PII] should have been his last day of insurance.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] That's odd because I'm showing he's his pay to date is [PII].
[AGENT][NEUTRAL] So even if.
[AGENT][NEUTRAL] I'm not showing any activity on this account since.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] But you're saying he should have been covered up until [PII].
[CUSTOMER][NEUTRAL] Until [PII], yeah.
[AGENT][NEUTRAL] Well we'll need to, I mean he can submit the claim, um, he just.
[AGENT][NEUTRAL] But um if he submits it now before we get his coverage corrected it's gonna deny.
[AGENT][NEUTRAL] Um, or it's gonna be held up.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] It's weird because I sent let me see if I could find a response on [PII] I submitted a term request.
[CUSTOMER][NEUTRAL] To bill billing billing call right at [PII] for 3 employees and I'm pretty sure I got a response back that they were returned properly.
[CUSTOMER][NEUTRAL] So I just find that strange. hold on, let's see.
[AGENT][NEUTRAL] Yeah, because it is showing that they're only paid up to [PII].
[CUSTOMER][POSITIVE] Yeah, and I, I even got um.
[CUSTOMER][NEUTRAL] I got a response the same day.
[CUSTOMER][NEUTRAL] Saying good afternoon. We have received your email request termination of a policy. The request is complete. [PII] termination date [PII]. Policy number 1566168, assuming that's his member number.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Termination effective [PII].
[AGENT][NEUTRAL] Well they need to update his.
[AGENT][NEUTRAL] Let me get someone in bill on the line to help us because we need to fix this first before we submit a claim because the claim is on a only gonna either deny or be held up saying that we're waiting for premium.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And I'm sure the group has paid.
[AGENT][NEUTRAL] Since [PII].
[CUSTOMER][NEUTRAL] All their invoices this group was.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Yeah, yeah, for sure.
[CUSTOMER][NEUTRAL] I just renewed them a little, you know, in in January that's that's.
[AGENT][NEUTRAL] OK, let me get someone from, I'm sorry, your first name again please? I'm sorry.
[CUSTOMER][NEUTRAL] [PII] my name.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK. All right, one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] I'm transferring.
[CUSTOMER][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[AGENT][NEUTRAL] Hi [PII], this is [PII] in claims. I have [PII] on my back line, um, he's an agent, um.
[AGENT][NEUTRAL] With group number 199.
[AGENT][NEUTRAL] 93
[AGENT][POSITIVE] [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] He's calling, he was calling initially about.
[AGENT][NEUTRAL] Um, a member that was termed last year that was having problems filing a claim, but I noticed that we only have him paid up.
[AGENT][NEUTRAL] To [PII].
[AGENT][NEUTRAL] Um, let me give you the policy number.
[CUSTOMER][NEUTRAL] Sorry, go ahead.
[AGENT][NEUTRAL] 1566168.
[CUSTOMER][NEUTRAL] Let me pull it up real quick.
[CUSTOMER][NEUTRAL] Yeah it looks like they did it by file uh let's see.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I can't remember what you do.
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] It's like they submitted a file feed.
[CUSTOMER][NEUTRAL] All right, no, come on boy.
[CUSTOMER][NEUTRAL] So that we received it from the group.
[CUSTOMER][NEUTRAL] Um, November of last year.
[CUSTOMER][NEUTRAL] But they were, what um
[CUSTOMER][POSITIVE] I apologize. I'm thinking a lot out loud.
[CUSTOMER][NEUTRAL] Yeah, I have him termed as a 12124.
[AGENT][NEGATIVE] Right, but we're calling because I, if I can't help him file a claim for this member until this coverage gets straight because once the claim is uploaded and there's no it's showing us it's no premium since [PII].
[AGENT][NEUTRAL] So we're gonna either deny or the claim will be denied.
[CUSTOMER][NEUTRAL] Uh, well,
[CUSTOMER][NEUTRAL] Would you give me that policy number real quick?
[AGENT][NEUTRAL] 15
[CUSTOMER][NEUTRAL] I, I apologize. I'm looking at a different.
[AGENT][NEUTRAL] 1566168
[AGENT][NEUTRAL] In the lion, I'm in lion, I'm sorry.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Alright, so I have them paid through 121 of 24.
[AGENT][NEUTRAL] In Lyon?
[CUSTOMER][NEUTRAL] Mhm. 1566168.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] What's the name on the policy?
[CUSTOMER][NEUTRAL] Yeah, that's, oh well, yeah, that I just have [PII] is probably a dependent.
[CUSTOMER][NEUTRAL] Let me see here. Oh, IT.
[CUSTOMER][NEUTRAL] Yes, I have page you date [PII].
[AGENT][NEUTRAL] And you're in line.
[CUSTOMER][NEUTRAL] They had, yes, ma'am. They've had uh 4 different policies, but the last one went from [PII].
[AGENT][NEUTRAL] I must be in, hold on a second.
[AGENT][NEUTRAL] Maybe I'm in a different line. Did I pull up the QA? Lord have [PII]. I don't pull up the QA.
[AGENT][NEGATIVE] I should have known when it took so long to load.
[CUSTOMER][NEGATIVE] Oh no.
[AGENT][NEUTRAL] OK, I'm in the QA. I'm not in the production. Oh my God, OK, because I was like, we, why is he showing active?
[AGENT][POSITIVE] It was great because he was showing active. He was showing active, but we didn't have any, there we go. OK. I'm good now. I was in the QA instead of the production.
[CUSTOMER][NEUTRAL] Oh, that's strange.
[AGENT][NEUTRAL] I need to remove that from my desk.
[CUSTOMER][POSITIVE] Yeah, those, they, they look just alike, so it's easily done.
[AGENT][NEUTRAL] Yeah, I, yeah, I was like, how did we, how is he still active and we ain't got premiums since [PII].
[CUSTOMER][NEGATIVE] They should have some kind of difference.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][POSITIVE] OK. Now it's making sense. OK, I'm good now. Thank you.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] OK. Yes, ma'am. Have a great day.
[AGENT][POSITIVE] Alrighty bye bye.
[AGENT][NEUTRAL] Thank you so much for your patience, Roger. OK, so I just spoke with billing and they just confirmed the pay to date was 12-1 of 2024. OK, so does you are does is he wanting you to send in the um information to have the claim processed?
[CUSTOMER][NEUTRAL] I mean, can you check to see if there's even a claim on file from the providers because that might be the reason why the provider hasn't got paid this whole time.
[AGENT][NEUTRAL] And this was for um a claim in October. The last claim we received was [PII] [PII].
[CUSTOMER][POSITIVE] That's exactly the one that I need paid.
[CUSTOMER][NEUTRAL] Florida Medical Center.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Now let me see who this is now because it looks like.
[AGENT][NEUTRAL] Let me see.
[CUSTOMER][NEUTRAL] I don't have the total charge, um, but I know the amount due is 350.
[CUSTOMER][NEUTRAL] In which you'll get I think 250 of it paid by APL.
[AGENT][NEUTRAL] That doesn't sound right because it looks like the patient responsibility on this claim was $125 and we paid that so let me just see who actually filed this claim because if you went, if this is an ER visit then.
[AGENT][NEUTRAL] More than 1 person, you normally get 3 bills when you go to the ER and we only got 1. Let me just check.
[CUSTOMER][NEUTRAL] I don't think it was in ER.
[AGENT][NEGATIVE] No, it wasn't OK.
[CUSTOMER][NEUTRAL] Hm.
[AGENT][NEUTRAL] 204-254. OK, let's see.
[AGENT][NEUTRAL] This was from MBBRadilogy Stewart, Florida Medical Center.
[CUSTOMER][NEUTRAL] That Florida Medical Center sounds.
[CUSTOMER][NEUTRAL] Yeah this says here Florida Medical Center.
[CUSTOMER][NEUTRAL] Um, so you, you guys pay it?
[AGENT][NEUTRAL] We pay, this is, it looks like he had a diagnostic procedure done and this was the professional, the doctor's fee, I guess. I don't know if this is the test or her reading the test, but this this claim that we received that the co-insurance was $125 and we paid that, but that's the only bill that we received.
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] So if there were other costs associated with it, we haven't received those claims.
[CUSTOMER][NEUTRAL] Do you is there like an EOB that you can send me?
[AGENT][NEUTRAL] I wouldn't be able to send you his EOB because that would be like medical.
[CUSTOMER][NEUTRAL] What what what what was the total charge on that?
[AGENT][NEUTRAL] The total charge was $2150.
[CUSTOMER][NEUTRAL] On that uh floor.
[CUSTOMER][NEUTRAL] So 2150 and then you guys paid how much?
[AGENT][NEUTRAL] 125.
[CUSTOMER][NEUTRAL] You paid 125. What, what would you, so 2150, is that what the weird thing is is that he, he has an outpatient benefit of.
[CUSTOMER][NEUTRAL] I thought it was 250 per day.
[CUSTOMER][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] Sorry, it's 200 per day.
[AGENT][NEUTRAL] So he would have $75 left for that day.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Does that show as being paid elsewhere or any reason why this one didn't pay the full 200?
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] What full 200?
[CUSTOMER][NEUTRAL] He he has a benefit of $200 per day, so why on this claim was only $125 paid.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Because that's all he owed.
[CUSTOMER][NEUTRAL] Oh, he, uh, you're showing he only owed to a 125.
[AGENT][NEUTRAL] Right, the co-insurance for the claim was $125 and we paid $125.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, do you show any other claim that was rejected from that day?
[AGENT][NEUTRAL] There's no other claims. That's what I was saying to you. We only got one claim for that day, which is kinda odd for a diagnostic procedure. That's why I'm saying somebody hasn't billed us.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so let me see if he can get me a detailed invoice, um, along with the EOB, see if we can submit it, but again at the same time he's only gonna be.
[CUSTOMER][POSITIVE] He's only gonna have $75 of benefits um left over. OK, alright, I got this I got this scoop right, thank you so much.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] OK, was there anything else I could assist with today?
[CUSTOMER][POSITIVE] No, that's it, have a good one.
[AGENT][POSITIVE] Alright, thank you for calling APO. Have a good day.
[CUSTOMER][NEUTRAL] Alright
[CUSTOMER][POSITIVE] Thank you you too bye