AccountId: 011433970860
ContactId: dd6b0cd6-bf2e-49a5-9183-52f067a1d4c9
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1407790 ms
Total Talk Time (AGENT): 496309 ms
Total Talk Time (CUSTOMER): 387309 ms
Interruptions: 1
Overall Sentiment: AGENT=1.3, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/06/dd6b0cd6-bf2e-49a5-9183-52f067a1d4c9_20250106T21:34_UTC.wav
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[AGENT][NEUTRAL] Hi, thank you for calling APL. This is [PII]. How can I help you today?
[CUSTOMER][NEUTRAL] Um, [PII], my name is [PII], and, uh, this policy is under my husband, um, but he, uh, has given me, I think you guys have, uh, authorization to talk to me. So what can I get you 1st 32.
[AGENT][NEUTRAL] Yeah, do you mind if I get the policy number, please?
[CUSTOMER][NEUTRAL] Uh, the policy number is 01897865.
[AGENT][POSITIVE] 65 perfect and.
[AGENT][NEUTRAL] All right, I do see this policy pulled up. I am going to have you verify the information and then I'm going to try to find the form that will allow me to talk to you, OK?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Would you be able to verify for me your husband's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Uh, [PII], [PII], and um his date of birth is [PII].
[AGENT][POSITIVE] Wonderful. Thank you so much. And I'm so sorry, did I interrupt you asking me a question? I didn't mean to.
[CUSTOMER][NEGATIVE] No, no, you do not, no.
[AGENT][NEUTRAL] OK, perfect. Um, I'm gonna have you verify for me the mailing address on file if you can.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Wonderful thank you and then if you could verify the email and phone number on file as well.
[CUSTOMER][NEUTRAL] Um, the email is
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Um, no, [PII] maybe, uh, it's A Pella, it's his work email, um.
[CUSTOMER][NEUTRAL] Uh STL pillows.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] I wasn't ready for that one, hold on.
[AGENT][NEUTRAL] I'm sorry, I didn't mean to throw a curveball at you.
[CUSTOMER][NEUTRAL] That's OK. No, I, I got it here just a minute.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Oh, sorry.
[AGENT][POSITIVE] You're OK? No worries.
[AGENT][NEUTRAL] Um, would you be able to verify for me that, uh, phone number real quick?
[CUSTOMER][NEUTRAL] Um, sure, uh, [PII]. And his email is.
[AGENT][POSITIVE] Perfect. Thank you.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you so much. I really appreciate that. And I'm gonna have you hang tight while I try to find
[CUSTOMER][POSITIVE] No problem.
[AGENT][NEUTRAL] My documents.
[AGENT][NEUTRAL] I see.
[AGENT][NEUTRAL] And may I have your name as well, please?
[CUSTOMER][NEUTRAL] Uh, it's [PII].
[AGENT][POSITIVE] All right, perfect. Hey, I really appreciate you giving me the patience to go through and get that document. I was able to find it. And so I will be able to help you with anything on file. Um, how can I help you today, Ms. [PII]?
[CUSTOMER][NEUTRAL] Um, OK, well, it looks like you guys paid, um.
[CUSTOMER][NEUTRAL] Uh, on a, uh, on a quest diagnostics, it was, uh, it was, uh, some blood work that was done for my husband, but the bill was for $288 and only 3096 cents was paid. I don't see a dollar $92 charge.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] That for a reason why they wouldn't have paid the full amount.
[AGENT][NEUTRAL] OK. OK, I do see the claim for Quest Diagnostic and if you have that claim number, I just wanna make sure we're looking at the same one that ends in 572. Does that sound right?
[CUSTOMER][NEUTRAL] Uh, no, it was a, um, an old one, and so it ended in 6435.
[AGENT][NEUTRAL] 6435. OK, let me take a look for that.
[AGENT][NEUTRAL] I'm so sorry, would you actually mind just reading the whole claim number to me because I am only seeing a 6135 and I just, I know I'm overlooking it, I'm sure.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] No, um, like I said, it kinda
[CUSTOMER][NEUTRAL] Yeah, uh, well, uh, if you look at, uh, it's your claim number 35475.
[CUSTOMER][NEUTRAL] 72
[AGENT][POSITIVE] Oh, OK, perfect. Yes, I do see that right here. It looks like we paid $30.96 and let's see.
[AGENT][POSITIVE] Appreciate your patience. One second.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] It's, it's only from [PII], so you know.
[CUSTOMER][NEUTRAL] I've been waiting a long time to get this one.
[AGENT][NEUTRAL] Yeah, I, I didn't even realize that I didn't even catch that. OK, yeah, um, I'm just trying to pull up the like the letter that has all of the explanations on it.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] It's, I wish everything in here was like in order, but all the years are mixed together, so.
[CUSTOMER][NEUTRAL] Right.
[AGENT][POSITIVE] All right, it took its sweet time, but I do have that pulled up for you so it looks like.
[AGENT][NEUTRAL] On that, there was a procedure code, the one that's the 99214, and that one is a
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Like a consultation charge or like it's like a.
[AGENT][NEUTRAL] I don't know how to describe it, but it's like an administrative charge and so that one is not covered under the policy, um.
[CUSTOMER][NEUTRAL] Um, no, I, I get that, but on the, on the quest though, I don't understand. I don't see that code on the quest bill.
[AGENT][NEUTRAL] Uh, it looks like.
[AGENT][NEUTRAL] Yeah I guess let me look at the whole claim itself instead of the breakdown.
[CUSTOMER][NEUTRAL] But the things I was charged for were all uh
[CUSTOMER][NEUTRAL] Uh, procedures that cost, uh,
[CUSTOMER][NEGATIVE] Blood work that they did, so I, there was, shouldn't have been any administrative.
[CUSTOMER][MIXED] I, I, I realize it's only $1.92 and at this point I'm happy to get the 3096, but I just don't understand.
[AGENT][NEUTRAL] Yeah, no, that makes sense, um, let me see this came in.
[CUSTOMER][NEUTRAL] It made me send the um the explanation of benefits where the, the blood work was ordered and it was uh ordered by his heart doctor. So I don't know if they got confused when they saw that. I don't, I don't know.
[CUSTOMER][NEUTRAL] Because I know his office visits aren't paid for, I know that.
[CUSTOMER][NEUTRAL] Unless they're doing something like he's had um
[CUSTOMER][NEUTRAL] He, his dermatologist has removed um
[CUSTOMER][NEUTRAL] Uh, melanoma, so sometimes those are paid for, not his initial visit, but the surgery that they do in the room, then that is.
[AGENT][NEUTRAL] Like the treatment. Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] So I get that, but, but I don't understand why uh blood work bill would not be paid in full.
[CUSTOMER][NEUTRAL] I think in the past, and I don't know if I can find one, but.
[AGENT][NEUTRAL] So I'm looking at the claim they sent us to see if I can help you with that, but if I can't figure it out what I'll do is I'll request for someone who processes the claims they might have more information to get back with you, but I'm gonna take a look at the claim that was sent to us and see if I can figure out um.
[AGENT][NEUTRAL] How that came through for you.
[CUSTOMER][NEGATIVE] And like they said they sent it in September, and when I called in at the end of December, they said you guys said you didn't have it.
[CUSTOMER][NEUTRAL] And then all of a sudden, on the [PII], this money got deposited into my account.
[AGENT][NEUTRAL] Yeah, it looks like we received it [PII] on our side, so maybe they resent it.
[CUSTOMER][NEUTRAL] So you get
[CUSTOMER][NEUTRAL] No, so that's what I said because you guys asked for my explanation of benefits.
[AGENT][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] And if you look over on uh the confirmation number, there's the uh it's OSC 90976 and OSC 90,990. 1 of them is the bill, one of them is the
[CUSTOMER][NEUTRAL] Uh, explanation of benefits.
[CUSTOMER][NEUTRAL] Those are uploads that I had to send you.
[AGENT][POSITIVE] OK, that makes a lot of sense. I'm glad you sent this to us though, um, instead of just waiting for them.
[AGENT][NEUTRAL] All right my friend, I'm very sorry, so I don't process claims like claims. I do look at them a lot so sometimes I can identify what I'm looking at or like why something was done, um.
[AGENT][NEUTRAL] Just as somebody who doesn't process them but sees them all the time. But unfortunately, I am not able to identify why some of it was denied and why some of it wasn't. And so what I can do though is I absolutely can go ahead and put in a request for somebody to review the claim and reach out to you and help you understand that a little better, a little better.
[AGENT][NEUTRAL] If that's something you would like.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Uh, yeah, that'd be great.
[AGENT][POSITIVE] OK, perfect. I'm gonna have you just hang out with me for one second and I'm gonna get this request filled out, OK?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[AGENT][POSITIVE] Are you having a fabulous [PII] so far, ma'am?
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] Oh no, I'm sorry.
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Are you, you're in [PII]? No?
[AGENT][NEUTRAL] Yes, I am.
[CUSTOMER][NEUTRAL] Yeah, did you guys get some snow? No?
[AGENT][MIXED] It wasn't bad, like it's cold and we had a light dusting last night and it froze into crunchy little bits, but I mean, it was sunny today, so it all kind of just melted away. I am worried about Friday though, it looks like the weather is gonna be a little worse.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, we, uh, we, some places got
[CUSTOMER][NEUTRAL] Between the ice and snow, they got 12 inches. So yeah, we, we're, uh, we've been cooped up. We had a, we went day drinking Saturday before uh the snow came and.
[AGENT][POSITIVE] Yes, that was the right move.
[AGENT][NEUTRAL] And ma'am, do you mind if I get a good call back number from you?
[CUSTOMER][NEUTRAL] Um, my number would be [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Perfect. And is it [PII]? I'm so sorry. I should have asked, but I didn't.
[CUSTOMER][NEUTRAL] No, no, no. Uh, it's no [PII]
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So what I have here for them is I have insured's wife [PII] called for claim denial explanation, authorization on file, would like further explanation about why some of the claim was not paid. Callback number [PII]. Did I get that correct?
[CUSTOMER][NEUTRAL] Uh, you did, um, are you gonna put the, uh, the file number that we're looking at, or is that already on there somewhere else?
[AGENT][NEUTRAL] It is, but it's in the, yeah, it has a different section where I type in the claim number we want to look at. And then I'm going ahead, I'm going to submit that. Typically, the turnaround time is about 24 hours to receive a call back. So you should hear back from somebody I would say by tomorrow evening at the latest.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then
[AGENT][NEUTRAL] How else can I help you today, Miss [PII]?
[CUSTOMER][NEUTRAL] Uh, that's all. Um, I'm just, uh, I just struggle with this because I, the bills come late and then sometimes I don't know, I guess because I submitted it, that's why they paid it to us.
[AGENT][NEUTRAL] Yes, if you submit the claim, the money comes to you and if the provider submits the claim, the money goes to them.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right, um,
[CUSTOMER][NEUTRAL] Yeah, because they've been and even if they're, even if it's been submitted by the provider and you're asking for more information, you're still gonna send that money to me.
[AGENT][NEUTRAL] Um, if the
[AGENT][NEUTRAL] So because we didn't have the claim on file from the provider and you sent us all the information, it was considered that you made the claim, um, but say the provider.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Submitted a claim and we needed more information and you provided it. I believe the money would go to the, it's like whoever initiates the the claim process.
[CUSTOMER][NEUTRAL] OK. um, can you look at one more?
[CUSTOMER][NEUTRAL] Which is another one that I, I, I submitted but it was back in October of last year and you guys cut it.
[AGENT][POSITIVE] Yes, absolutely.
[CUSTOMER][NEUTRAL] Cut us a check for 209-61.
[CUSTOMER][NEUTRAL] Do you see that one?
[AGENT][NEUTRAL] Um, you said it was in October.
[CUSTOMER][NEUTRAL] Um, it's number.
[CUSTOMER][NEUTRAL] 352-20.
[CUSTOMER][NEUTRAL] 48
[AGENT][NEUTRAL] Yes, I do see that one.
[CUSTOMER][NEGATIVE] Um, can you tell me what you're paying there because that was just that one just doesn't match anything I submitted.
[AGENT][NEUTRAL] Uh looks like it came from Mercy Labs in Saint [PII].
[CUSTOMER][NEUTRAL] Well, well, again, if it came from them, why would you send.
[AGENT][NEUTRAL] Or I'm sorry, that's like the provider on file. Here, let me pull up how it came into us.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][MIXED] So, we have like a cute little shortcuts to like open up files, but mine hasn't been working all day so I.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] That's OK.
[AGENT][NEUTRAL] OK, we received this [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] It looks like it was uploaded through the online portal on.
[AGENT][NEUTRAL] The [PII] and it looks like
[AGENT][NEUTRAL] It was 7 pages. Well, the first ones are like cover letters, and we received an explanation of benefits from Aetna.
[AGENT][NEUTRAL] Um, it looks like the.
[AGENT][NEUTRAL] Explanation of benefits lists.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Lists, um.
[AGENT][NEUTRAL] Three different payment summaries, one for the provider Jonathan MC, uh, one for Mercy Clinic surgical Specialist LLC and then another provider is Mercy Lab Saint Louis LLC.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] And it looks like.
[AGENT][POSITIVE] This one paid out.
[AGENT][NEUTRAL] For benefits for the charges involved with Mercy Lab Saint Louis.
[AGENT][NEUTRAL] That were submitted to us.
[CUSTOMER][NEUTRAL] 2.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] OK, I see.
[CUSTOMER][NEUTRAL] Um, so it was the 180 74, and the 28, see, but when I sent this, I highlighted the one I was talking about that the bill was provided for, uh, for 152 44.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Alright, I do you see the 152 44, it says medical services. 88. Hold on, let me go into the remarks.
[AGENT][NEUTRAL] So,
[AGENT][NEUTRAL] Of course, OK, hold.
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] So those ones, the 883-24, all of the ones on [PII], there was the three charges and.
[AGENT][NEUTRAL] It says the policy benefit for this listed date of service has already been paid directly to the provider, so it looks like that particular provider [PII] already submitted his own claim, and so that part of it has already been paid to him on the claim that he submitted.
[CUSTOMER][NEUTRAL] OK. All right.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] I understand now. OK.
[CUSTOMER][POSITIVE] That makes sense. OK, thank you so much.
[AGENT][POSITIVE] Oh, it's my pleasure. I'm so, so happy I could help you and if there's anything else you need, please give us a call, let us know, we're gonna do our best for you.
[CUSTOMER][POSITIVE] All right, thanks so much, [PII]. You have a great day. Mhm.
[AGENT][POSITIVE] My pleasure. You too, Ms. [PII], and somebody should be in touch with you hopefully within the next 24 hours, my friend, OK?
[CUSTOMER][POSITIVE] OK, thank you very much.
[AGENT][POSITIVE] My pleasure. Take care.
[CUSTOMER][NEUTRAL] Mm bye.
[AGENT][NEUTRAL] Bye.