AccountId: 011433970860
ContactId: e50420a8-6a59-47ec-992a-00d4a59b90da
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 832840 ms
Total Talk Time (AGENT): 407895 ms
Total Talk Time (CUSTOMER): 287583 ms
Interruptions: 2
Overall Sentiment: AGENT=0.8, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/25/e50420a8-6a59-47ec-992a-00d4a59b90da_20250325T14:21_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Uh, my policy number is 97205.
[CUSTOMER][NEUTRAL] My name is [PII].
[AGENT][NEUTRAL] Hey, hi, [PII]. How are you today?
[CUSTOMER][NEUTRAL] Um, uh, so, so, trying to figure out what's going on with the, with the claim.
[AGENT][NEUTRAL] I understand. OK, we're needing to check on a claim for you.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Alright, uh, really quick, [PII], can I get a good call back number from you in case we're disconnected please?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, thank you. And then just gonna verify some information from you really quick. Can I get your date of birth, please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you and then can I get your mailing address?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Perfect. The last thing I need is the email address we've got on file for you. uh, looks like it is a Yahoo account.
[CUSTOMER][NEUTRAL] Uh, [PII].
[AGENT][POSITIVE] Perfect, thank you so much for verifying that information, [PII]. OK, now was this claim for you or was this for uh [PII]?
[CUSTOMER][NEUTRAL] For me.
[AGENT][NEUTRAL] It was for you, OK. Alright, bear with me just a moment, let me take a look.
[AGENT][NEUTRAL] OK, so the last claim that I'm showing it was submitted, uh, [PII]. Does that sound right to you?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, all right, bear with me just a moment, let me take a look here.
[AGENT][NEUTRAL] OK, so there were a few items of course under this claim, um, so this policy does not provide any sort of benefits for office visits or laboratory and or diagnostic test benefits so we were unable to pay anything for that for the chemo, uh, we are just missing some information we're needing a copy of the explanation of benefits from your primary insurance for those dates of service.
[CUSTOMER][NEUTRAL] You talking about the uh for Medicare.
[AGENT][NEUTRAL] Uh, yeah, so whoever is your primary provider, um, we would just need those.
[CUSTOMER][NEUTRAL] I, I, I sent that in.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] I sent that in. I, I, I, uh, I'm talking about.
[AGENT][NEUTRAL] You uh the explanation of benefits.
[CUSTOMER][NEUTRAL] I sent you the Medicare summary notice, the MSN reports.
[AGENT][NEUTRAL] Um, so, mhm.
[CUSTOMER][NEUTRAL] And I sent the uh the book.
[AGENT][NEUTRAL] OK, the explanation of benefits they don't use well I mean it depends on where you go that's something that you would generally get from the provider so wherever you went for treatment again it's just showing what they contributed to that treatment.
[CUSTOMER][NEUTRAL] Is that what
[CUSTOMER][NEGATIVE] So what are you, what are you asking me, what are you telling me that you need that you don't have?
[AGENT][NEUTRAL] The explanation of benefits.
[CUSTOMER][NEUTRAL] Because that's all I ever.
[AGENT][NEUTRAL] OK, OK, um, if you would like [PII], I could put you on a brief hold and reach out to our claims specialist just so they can kind of go over what was submitted.
[CUSTOMER][NEUTRAL] Please, please do.
[AGENT][POSITIVE] All right. Yes, sir. Give me just a moment, I'll get right back with you.
[CUSTOMER][NEUTRAL] And I I I. Mhm.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Furring
[CUSTOMER][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hi [PII], this is [PII] over on the care team. How are you today?
[CUSTOMER][POSITIVE] I'm good how are you [PII]?
[AGENT][NEUTRAL] Doing all right, thank you. um I've got a member on the line who's calling regarding a cancer claim um and it's stating for chemo that of course we need the primary EOB and uh he's pretty adamant that he did send that so he would like to review what was submitted.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, give me just a second.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Alright, can I get that policy number?
[AGENT][NEUTRAL] Yeah it's 972-05.
[AGENT][NEUTRAL] And it is for part 2, and that is who we're speaking with [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Part two, is it the most recent one I'm assuming.
[AGENT][NEUTRAL] Yeah, the one ending in 837.
[CUSTOMER][NEUTRAL] OK, let me get that pulled up so I can see what he submitted.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Hm let's see.
[CUSTOMER][NEUTRAL] Um, OK, so he is saying that he did submit the EOB for chemo.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, so.
[CUSTOMER][NEUTRAL] What do we have the bills and then we have.
[CUSTOMER][NEUTRAL] Oh it's from the [PII].
[CUSTOMER][NEUTRAL] Oh, that's office visit. Sorry, let me look at the next page.
[AGENT][NEUTRAL] Yeah, I did explain that to him.
[CUSTOMER][NEUTRAL] Chemo admin.
[CUSTOMER][NEUTRAL] So it said insurance pending, it's not actually been processed, it looks like.
[AGENT][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] Um, so,
[CUSTOMER][NEUTRAL] Like on their bill or whatever it says charges, payments, adjustments and then it has like the 87 for the administration.
[AGENT][NEUTRAL] But he just needs to give us the updated.
[CUSTOMER][NEUTRAL] And then
[CUSTOMER][NEUTRAL] Yeah, just like an updated one because it says insurance pending and then patient balance so it they may or may not approve those full amounts and so they build Medicare and so we need like either an updated version of this that shows what was paid by the insurance or we need something from Medicare.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Right.
[AGENT][POSITIVE] Got you OK.
[CUSTOMER][NEUTRAL] So he did submit something we could have used it's just that it's pending it had not been pro right it doesn't show anything that they may have paid it just says that they did bill Medicare that they just had not received anything and we need that information.
[AGENT][NEGATIVE] Doesn't show an amount.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Got you. OK, well I sure appreciate you checking that. I'll, I'll go ahead and let him know that.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Alright, thank you, bye bye.
[CUSTOMER][NEUTRAL] You're welcome, [PII]. Bye.
[AGENT][POSITIVE] Alright, [PII], I'm so sorry about that wait are you still with me?
[CUSTOMER][POSITIVE] Oh yes ma'am.
[AGENT][NEUTRAL] OK, so I did touch base with them. Uh, we did look over what was submitted. You did send us the right forms, however, I think, um, it was a bit too soon, so when it shows we need to have it be a dollar amount, of course that um, Medicare did pay and under the form that you sent it said it was pending.
[AGENT][NEUTRAL] So it like the amount that they had paid so we simply need an updated copy of that form that shows what they did pay and again you can get that from the provider um or from Medicare, whichever is easier for you uh to go to and just ask them for that updated explanation of benefits just showing that dollar amount.
[CUSTOMER][NEUTRAL] OK, I just, I, I sent it to, I sent it to you again.
[AGENT][NEUTRAL] I'm sorry.
[CUSTOMER][NEUTRAL] And uh,
[AGENT][NEUTRAL] 00, when was that sent?
[CUSTOMER][NEUTRAL] I just sent it.
[AGENT][NEUTRAL] Um, how did you send that to us? Was it by, uh, mail? Did you use our?
[CUSTOMER][NEUTRAL] Electronic electronic electronics.
[AGENT][NEUTRAL] Electronically, OK.
[AGENT][NEUTRAL] OK, um, so depending on how it was sent of course if it was through our online portal uh that should get to us pretty quick, but it can still take about a day or so for that to reflect that that's been received, um, so if you sent it, you know, just today or yesterday even it can take a little bit and then of course from there, uh, it can take about 7 to 10 business days for that information to complete processing. So if you wanted to confirm that we did receive that, um, if it was sent through our online portal.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I would say um tomorrow or Thursday you give us a call back we can verify that it's been received but again to process it can take up to 10 business days.
[CUSTOMER][NEUTRAL] OK, you, uh,
[CUSTOMER][NEUTRAL] You know, uh, every time Medicare, uh, they'll send you the summary, maybe 3 months after your visit.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Oh,
[CUSTOMER][NEUTRAL] And and uh and uh so that's how I'm able to send you the Medicare summary and uh I'm looking at it now and it's and it's showing that uh.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] The uh the amount that they, they were charged was like $6800 and it's showing that Medicare approved $300 and it's showing me what I.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, and that's on the first one I sent you too, and but I just sent it again. It said Medicare approved, or am I, I, I'm asking you this to see if I'm saying it right. It's showing the amount charged and then it's showing it.
[AGENT][NEUTRAL] OK, so
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] The amount approved, is that what you're looking for?
[AGENT][NEUTRAL] So it is a bit different and it is very confusing and I apologize for that. What it looks like the form that you sent was that they did approve it but it was still processing the amount that it was actually going to pay because when we looked where how much it paid it simply says pending.
[AGENT][NEUTRAL] So if you we can still check to see if that information you sent um recently was what we needed but it looks like we just need that updated form that shows it once it's completed its own processing.
[CUSTOMER][NEUTRAL] Well
[CUSTOMER][NEUTRAL] OK, what I'm looking at it says that.
[CUSTOMER][NEUTRAL] Medicare approved amount.
[AGENT][NEUTRAL] Do you see anything on the form that you're looking at that says pending?
[CUSTOMER][NEUTRAL] It's a 3.
[CUSTOMER][NEUTRAL] No, it doesn't say pending.
[AGENT][NEUTRAL] OK, so that what we've received, what I can see on my end that's what uh it does show is pending for the dollar amount. So if you we can see if the what you sent us, um, once that completes processing if that's sufficient, but honestly just for the sake of, you know, so you're not having to wait any longer than necessary, I would call your provider or Medicare, whichever you prefer and ask them for that updated copy of the explanation of benefits for the dates of service.
[CUSTOMER][NEUTRAL] OK, all right.
[AGENT][NEUTRAL] And they should be able to send that to you electronically as well um like through an email um and then of course once you get that you can simply upload that right to us.
[CUSTOMER][NEUTRAL] Right, OK, but you can't see the one I just uploaded, huh?
[AGENT][NEUTRAL] No, sir, um, it might be a bit too soon.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Right, because I did it through your portal.
[AGENT][NEUTRAL] Yes, yes, well those do get to us pretty quick again it can take a while for those to process.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, I will call Medicare, but I'm almost sure that this is the right one I'm looking at.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEGATIVE] I know we had the same problem every time.
[AGENT][NEUTRAL] Well, again, it's you, you are definitely on top of what you're supposed to be doing you're sending us all of the right stuff. It just looks like it might be a bit too soon, um, for Medicare's and you know like that it might take them a bit to actually make that payment if that makes sense.
[CUSTOMER][NEUTRAL] Every time we process it.
[CUSTOMER][NEUTRAL] Mm, I, I, I'm gonna call him and make sure. I'm gonna do like you say that. I'm gonna do what you just told me to do.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] If I can get through.
[AGENT][POSITIVE] Well, and again if it's easier you can just call wherever you went for treatment, the provider, they will have that information too so whichever one is easier for you.
[CUSTOMER][NEUTRAL] I don't call Medicare because that's gonna have to give me the statement.
[AGENT][NEUTRAL] The provider would have that as well um but that's whatever is easier for you.
[CUSTOMER][NEUTRAL] Um, uh, well I had to.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, did you have did you have any other questions for me?
[CUSTOMER][POSITIVE] OK then I'll do that too. Alright, I'm gonna do, I'm gonna do both.
[CUSTOMER][NEUTRAL] No, ma'am, and I, I got you I got your uh extension is [PII].
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] Um, so I don't actually have my own extension, um, but, uh, the whatever number you called, um, our entire team, I will be notating what we've spoken about, so if you need to call back they'll know, um, what was going on.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK, are you still working from home or you back in the office?
[AGENT][NEUTRAL] Oh no sir, I work from home.
[CUSTOMER][NEUTRAL] Yeah, well, I thought they was doing away with all that.
[AGENT][NEUTRAL] I think it depends, um, different places sure are.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, OK then, alright.
[AGENT][POSITIVE] Alright, well thanks [PII]. I hope you have a great rest of your day.
[CUSTOMER][NEUTRAL] Alright.
[CUSTOMER][NEUTRAL] Alright, bye.
[AGENT][NEUTRAL] Bye bye.