AccountId: 011433970860
ContactId: e18681cb-8308-4167-972b-91c7e0ef2b29
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 787299 ms
Total Talk Time (AGENT): 332951 ms
Total Talk Time (CUSTOMER): 431933 ms
Interruptions: 6
Overall Sentiment: AGENT=1.6, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/26/e18681cb-8308-4167-972b-91c7e0ef2b29_20250326T16:08_UTC.wav
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[AGENT][POSITIVE] Good morning thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. My name is [PII] and I'm a um customer of yours.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, and I had a couple of questions about the couple of the claims that I have submitted.
[CUSTOMER][NEUTRAL] Um, it doesn't seem that they, they ever get uh paid out. So my son has been, um,
[CUSTOMER][NEUTRAL] Um, unfortunately, a frequent customer of urgent care for Nicklaus Children's Hospital, and I was talking to our plan benefits administrator here at work, and, uh, he was telling me that the urgent care for Nicklaus should be covered. So, um, I submitted the.
[CUSTOMER][NEUTRAL] Uh explanation of benefits from United Healthcare, which is my uh main insurer. Uh, and then I received a notice that uh um I need additional information to provide additional information, so I called again APL to find out what is that additional information needed.
[CUSTOMER][NEUTRAL] And the lady told me that on each of the explanation of benefits paper I need to uh write, you know, for example, [PII] had a fever, so he was taken to urgent care and I did that and I still see the same results. So, um, what information do you need from me in order to review my account and tell me what is it that I'm not doing correctly all the time as it seems.
[AGENT][POSITIVE] Yes ma'am, and it would be my pleasure to assist you today. First of all, what is a good callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. And do you have your policy number available?
[CUSTOMER][NEUTRAL] 2491469
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And Ms. [PII], can you verify your date of birth and current mailing address, please, ma'am?
[CUSTOMER][NEUTRAL] [PII], uh, mailing address [PII].
[AGENT][NEUTRAL] All right.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And this is for [PII]?
[CUSTOMER][NEUTRAL] Huh?
[CUSTOMER][NEUTRAL] [PII], correct.
[AGENT][NEUTRAL] OK, so let me take a look and see what's going on if you will bear with me just one quick moment.
[CUSTOMER][NEUTRAL] Of course, I always.
[AGENT][POSITIVE] Thank you. I appreciate that.
[CUSTOMER][POSITIVE] No problem.
[AGENT][POSITIVE] See what we can do to get these, if there's anything we can do to get this processed and paid for you.
[CUSTOMER][NEGATIVE] Yeah, because I've already covered the charges with uh the close children, uh, urgent care, but, uh, what our benefits plan administrator was telling me is like, oh, but, uh, because you paid them, they will reimburse you, but I, I don't seem to be following instructions well or I do not know what my issue is, but I don't seem to be able to get anything done here.
[AGENT][NEGATIVE] Well, we're gonna see what we can do. Hang on just a second. And I know that's frustrating.
[CUSTOMER][POSITIVE] Perfect, thank you so much.
[CUSTOMER][NEGATIVE] Yes, because it's, you know, after 34 calls we just quit, but now my boss charged me with doing this. Otherwise I'm not able to go to lunch.
[AGENT][NEUTRAL] Well, that's
[CUSTOMER][NEGATIVE] He said until I do this phone call and get this resolved, he's not allowing me to leave the office.
[AGENT][NEUTRAL] He wants you to be taken care of, doesn't he?
[CUSTOMER][NEUTRAL] OK
[AGENT][POSITIVE] That's a good boss. That's a good boss. OK.
[CUSTOMER][NEUTRAL] Exactly. So, I think he wants to prove me wrong because I'm telling him it doesn't work and he wants to prove me wrong that it works.
[AGENT][NEUTRAL] Well,
[AGENT][POSITIVE] Well, guess what? I wanna prove you wrong too, so let's see what we can do.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][POSITIVE] Perfect, thank you so much.
[AGENT][POSITIVE] My pleasure.
[CUSTOMER][NEUTRAL] Uh.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So it it looks to me that the main thing that they're needing.
[AGENT][NEUTRAL] It is going to be the diagnosis code. So your meddling gap policy only pays toward a sickness or injury diagnosis. For that reason, we have to have the diagnosis codes from Nicholas Children's.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, facilities. Now, and then of course, it is a secondary policy, so we always have to have your primary EOB and who is your primary insurance with?
[CUSTOMER][NEUTRAL] United Healthcare.
[AGENT][NEUTRAL] OK. So they do not put the diagnosis codes on the UnitedHealthcare explanation of benefits. Unfortunately, it would be so easy if they did. So we, um, what we will need is from Nicholas Children's. Now, um, we'll need a document with the diagnosis codes for each data service. Now, if you happen to have any walkout papers,
[AGENT][NEUTRAL] You know, like when you leave the doctor's office, they'll give you a summary of the reason for the visit.
[AGENT][NEUTRAL] Like [PII] was seen for pain in the left shoulder, or, you know, the reason he was seen and what they found.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] You can also contact [PII]'s.
[AGENT][NEUTRAL] And request a form from them for each date.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And you should not have any problems with getting them to send this to you. That form is called a CMS 1500. That is a C as in Charlie, M as in Mike, [PII].
[AGENT][NEUTRAL] That is actually the
[CUSTOMER][NEUTRAL] Well, I, um, I actually, I actually have an access to my [PII] account, so you want me to download all of the patients summary pages and send them to you?
[AGENT][NEUTRAL] If they have the diagnosis code listed or the reason for the visit. Now, you can check that and see if they have a code.
[CUSTOMER][NEUTRAL] But this is the thing, when I called.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Sorry, when I called APL, uh, the, the lady that I spoke with, she said that I don't need to, to worry about anything, just on each of the end of, uh, not the end of business, sorry, explanation of benefits document I need to, to write, uh, OK, on, uh, [PII] I took [PII] because he had high fever.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And, you know, that will suffice, so that does not suffice. Is that what you're telling me?
[AGENT][NEUTRAL] Unfortunately, we cannot accept written um diagnosis on EOBs anymore, and that's due to insurance laws and regulations. We have to have that documentation from the provider, meaning [PII]'s.
[AGENT][POSITIVE] And I do apologize.
[CUSTOMER][NEUTRAL] OK, no, no, no problem. So because each of those documents that you're referring to, the ones that I received when I'm departing the urgent care.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, they're like, I don't know, 20 pages and more.
[AGENT][NEUTRAL] Couple of pages long, yeah. Yeah.
[AGENT][NEUTRAL] So that CMS 1500 is a, I'm sorry.
[CUSTOMER][NEGATIVE] So, just because I, I would hate to, to do this and then call again and then it's another thing. So.
[AGENT][NEGATIVE] No, no, no. And you won't.
[CUSTOMER][NEUTRAL] Like for example, I'm, I'm uh.
[CUSTOMER][NEUTRAL] Yeah, I, I, I gotta ask because um I need to go to lunch. Remember my boss said no lunch until we resolved it.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right.
[CUSTOMER][POSITIVE] I really, really want to eat lunch today.
[AGENT][NEUTRAL] I don't blame you and you don't, and you don't need this cutting into your lunchtime.
[CUSTOMER][NEUTRAL] OK, so a document that says.
[CUSTOMER][NEUTRAL] Exactly. So, um, the document that says, uh, uh, patient summary and it says page patient discharge instructions and then it says arrival date and then diagnosis. Uh, let's say I have a viral pharyngitis. That's good.
[AGENT][POSITIVE] That's good.
[AGENT][POSITIVE] That is good.
[CUSTOMER][NEUTRAL] OK. And how do I get this over to those claims that you guys denied earlier?
[AGENT][NEUTRAL] So you can upload them on your portal the same way you did the original claims.
[AGENT][NEUTRAL] And they will review that.
[CUSTOMER][NEUTRAL] So, like a new claim or what?
[AGENT][NEUTRAL] It'll, it'll look like a new claim, but they will look in the history and realize that it is for, you know, the existing claims. It's just additional information.
[CUSTOMER][NEUTRAL] Uh-huh, they will attach them to the other ones. OK, because, uh, you know, I was trying previously to attach the, the one with the written note and it didn't work. OK.
[AGENT][NEUTRAL] That's right. It will have a different claim number.
[AGENT][NEUTRAL] Right, and unfortunately, just because of insurance regulations and laws, we have to have that documentation from the facility or the provider. And in the future, be sure to show your APL card with your primary insurance card when you go for medical services, and the provider should file the claims for you.
[CUSTOMER][NEUTRAL] I understand now.
[AGENT][NEUTRAL] And you wouldn't have to pay
[CUSTOMER][NEUTRAL] Well, the thing is that on, on the last one that I, um, I attended on [PII], uh, for my son's another urgent care visit.
[CUSTOMER][NEUTRAL] I provided the card and um for some reason like the the gentleman said oh I'm not gonna charge you the $50 because this APL thing is supposed to do at least that and if it covers any additional after we build United Healthcare, you know, um we'll let you know so I didn't pay the $50.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] But, uh, about 10 days ago I received uh another bill from Nicholas urgent care to tell me that I owe them the $50 and now when I'm looking at APL, it doesn't seem that you have paid anything for my son's visit on the [PII], even though I provided the card and the gentleman didn't charge me.
[AGENT][NEUTRAL] Well, we don't
[CUSTOMER][NEUTRAL] Anticipating that the $50 thing will work.
[AGENT][NEUTRAL] Yeah, see, we don't have a claim on file from them. They, I don't know if they didn't file the claim with APL or if they sent it and we have not received it, so you might wanna call them instead of paying that $50 you know, you might just wanna contact them and say I was checking on my claims with APL and they don't have a claim on file for that date from you.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] OK. I'm uh.
[AGENT][NEUTRAL] See if they can resubmit it. They can fax it directly to us as well.
[CUSTOMER][NEUTRAL] It's so strange though.
[AGENT][NEUTRAL] What was the data service?
[CUSTOMER][NEGATIVE] Like it's constantly.
[CUSTOMER][NEUTRAL] It was [PII].
[AGENT][NEUTRAL] Yeah, we do not have a claim on file for [PII] from [PII].
[CUSTOMER][NEUTRAL] Yeah, I looked at APL and um obviously because I was sharing my feedback that's why the plan administrator and my boss put me to this phone call now.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, um, I mean, I'll uh follow up with with them then.
[AGENT][NEUTRAL] Yeah. And with that,
[CUSTOMER][NEUTRAL] Because I do see that they have submitted the claim to, through United Healthcare already and all of that because, um, you know, I also had to go to the pharmacy to get antibiotics for my son and I see the, the whole claim is there.
[AGENT][MIXED] That's just hard. He is just having a hard time, is he? I certainly hope he gets to feeling better.
[CUSTOMER][NEUTRAL] Um, no, no, I mean, my, my son is totally fine. It was, uh, like a rush after an insect bite, but, you know, for some reason I still cannot get this thingy correct. Correct. Well, I'm gonna then.
[AGENT][POSITIVE] Oh good.
[AGENT][NEUTRAL] We're gonna get it taken care of, but we can just get those diagnosis codes.
[CUSTOMER][NEUTRAL] OK, well, no, what I'm gonna do now is, uh, I will submit the the patient summary paperwork that they provided to me.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And then um also now I will add the claim for the [PII] because there you will see the diagnosis together with the
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Explanation of benefits. All right, let me get to uploading then.
[AGENT][POSITIVE] All right. Well, it has been a pleasure to assist you, Ms. [PII], and I hope you enjoy your lunch. You tell them you need an extended lunchtime after dealing with this.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][POSITIVE] All right. Thank you so much.
[AGENT][POSITIVE] It's been a pleasure. Is there anything else I can help you with?
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] No, that was all. Thank you so much.
[AGENT][POSITIVE] And thank you for calling APO Ms. [PII]. You have a wonderful day.
[CUSTOMER][POSITIVE] You as well thank you.
[AGENT][POSITIVE] Thank you. Bye-bye.
[CUSTOMER][NEUTRAL] Bye bye.