AccountId: 011433970860
ContactId: e7e17eaf-5d82-4c4d-b076-ba165f258f7b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1088069 ms
Total Talk Time (AGENT): 466574 ms
Total Talk Time (CUSTOMER): 465242 ms
Interruptions: 4
Overall Sentiment: AGENT=0.4, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/05/e7e17eaf-5d82-4c4d-b076-ba165f258f7b_20250205T16:53_UTC.wav
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[AGENT][NEUTRAL] APL, this is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hey [PII], um, I am calling in regards to um a policy that I have with you all through my employer.
[AGENT][NEUTRAL] OK, and your name?
[CUSTOMER][NEUTRAL] Uh [PII].
[AGENT][NEUTRAL] [PII], OK, and what's the policy number, [PII]?
[CUSTOMER][NEUTRAL] It is 02544013.
[AGENT][POSITIVE] And a good phone number in case we're disconnected?
[CUSTOMER][NEUTRAL] Sure it's [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And what is your date of birth and your mailing address?
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][NEUTRAL] And your email address?
[CUSTOMER][NEUTRAL] Um, [PII].
[AGENT][POSITIVE] Thank you for that. And how can I help you today?
[CUSTOMER][NEUTRAL] Um, so I presented this card to my doctor's office and they said they couldn't find you in the system. Um, the address on the back of the card is a [PII]. The only thing that they could find in the system was [PII].
[AGENT][NEUTRAL] Yeah, that the address has been updated for some time, so same, that's our old um mailing address.
[CUSTOMER][NEUTRAL] What is the old one?
[AGENT][NEUTRAL] The [PII], the one that they have in their system.
[CUSTOMER][NEUTRAL] Oh, OK, um, so.
[CUSTOMER][NEUTRAL] I guess, um, so is she's gonna have any issues like submitting the claim through their system?
[AGENT][NEUTRAL] They would need the correct mailing address, which is what you just said, the [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The
[CUSTOMER][NEUTRAL] OK, alright, um, so they need to update that in their system, where do they get that information from because I know they're not just gonna take it by my word of mouth. Do they need to call you or how?
[AGENT][NEUTRAL] It, it's on your card.
[AGENT][NEUTRAL] Yes, yes.
[AGENT][NEUTRAL] From your ID card, from your ID card.
[CUSTOMER][NEUTRAL] OK, um, so I will let them know and then if they have any other questions I guess they can then call you guys then.
[AGENT][NEUTRAL] Yeah, they'll need to call us for benefits anyway, so we usually verify that information and include the mailing address.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, alright, and um let me just ask you one other question about this um so does does this card it it just like whatever my whatever is not paid through my initial insurance through United Healthcare this card picks up, is that correct?
[AGENT][NEUTRAL] Only the amounts applied towards your deductible co-insurance and or co-pay amounts of covered charges.
[CUSTOMER][NEUTRAL] It what? I'm sorry?
[AGENT][NEUTRAL] It, it only will reimburse the amounts that are applied towards your major medical deductible, your major medical co-insurance, and your major medical co-pay of covered charges. So it has to be covered under your policy.
[CUSTOMER][NEUTRAL] So how, because I don't really understand that. So how, how would that work? Like when I went to the doctor last Tuesday I had um an ultrasound done and the remaining um amount that was due after United Healthcare was like $94.38. So is that something that this policy would pick up?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] And how was that applied? Was it applied towards your calendar your deductible?
[CUSTOMER][NEUTRAL] Uh, I don't know how would I know that?
[AGENT][NEUTRAL] Yeah, it's on your major medical explanation of benefits. Do you receive those?
[CUSTOMER][NEUTRAL] Um, yeah, so let me just see, give me one second. I'm actually on UnitedHealthcare's website right now.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, sure.
[CUSTOMER][NEUTRAL] I'm gonna look at a different one because I don't have access to the explanation of benefits on that one yet, but I do have it on a dermatology appointment that I went to, so, um, the remaining balance that I owed after my dermatology appointment was 135. 23, um, so where would I because I've got the explanation of benefits, where would I see what you're talking about?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] OK, so that amount would either be in the deductible column, so there should be a deductible column, a co-insurance column, and a co-pay column on that EOB.
[CUSTOMER][NEUTRAL] Uh huh.
[CUSTOMER][NEUTRAL] OK, let's see.
[CUSTOMER][NEUTRAL] OK, so on here it's got um network and then to the right of it says deductible, um, maximum amount 5000 progress so far 723 62 and then out of pocket 8150 progress so far 91907, but there's no.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, there's no, let's see.
[AGENT][NEUTRAL] The document that you're looking at, does it say explanation of benefits at the top?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm yeah.
[AGENT][NEUTRAL] OK, and so it should list the date of service, the date that you had the test done?
[AGENT][NEUTRAL] Or went to the doctor?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] You see that?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then it should.
[CUSTOMER][NEUTRAL] But I don't
[CUSTOMER][NEUTRAL] Go ahead.
[AGENT][NEUTRAL] Just tell me what you see.
[AGENT][NEUTRAL] What columns do you see?
[CUSTOMER][NEUTRAL] OK, so, um, so there's a 2nd page and it has, um, provide provider bill amount say plan allowed amount other other coverage paid your plan paid applied to deductible and then co-pay, co-insurance and plan does not cover an amount you owe.
[AGENT][NEUTRAL] OK, so is there any dollars in the deductible column or does it say 0?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] There's only one column that says applied to deductible is that the one you're talking about?
[AGENT][NEUTRAL] And what amount is in that column?
[CUSTOMER][NEUTRAL] Um, well, there's, um, actually, um, there's multiple lines listed here like, um.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Uh let's see 1234. There's like 4 different lines and then on each of those apply to deductibles says 6791 on one of them and then 687 on the other one.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK, and so.
[CUSTOMER][NEUTRAL] Um
[AGENT][NEUTRAL] As I was saying earlier, any amounts that are applied towards your deductible, so those, it sounds like those have been applied towards your calendar, your deductible if it's in that deductible column.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And so your meddling policy with APL.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] We will pick up or reimburse or pay out the amount that appear in your deductible column.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And next to that should be a co-insurance column and then maybe a co-pay column.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] So any dollars that are in either of those three columns, when it's covered under your policy, we will, we'll pay those dollars to the provider, we'll reimburse the provider those amounts so you wouldn't have to pay anything since this is like a supplemental policy to your major medical.
[CUSTOMER][NEUTRAL] Yes, mhm.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK, so
[CUSTOMER][NEUTRAL] OK, so any time they're in those 3 columns you will pick up that difference.
[AGENT][NEUTRAL] And it has to be covered by your policy, so the ELB that you're looking at now, what service was that for?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] What did they do on that day?
[CUSTOMER][NEUTRAL] Um, that was a dermatology appointment, so they froze an area and then just did like a full body checkup.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So it sounds like it was some treatment done.
[AGENT][NEUTRAL] What are the codes? I think you saw some procedure codes.
[CUSTOMER][NEUTRAL] Um, let's see, where would I see the code.
[AGENT][NEUTRAL] Like 5 line items, 4 or 5 line items?
[CUSTOMER][NEUTRAL] I, I don't, I mean there's nothing specifically that's, oh wait, here it is, um, like here's a code, um, the.
[AGENT][NEUTRAL] Procedure code or CPT code?
[CUSTOMER][NEUTRAL] Um, PP.
[CUSTOMER][NEUTRAL] 0008.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] So it's gonna be a column it's gonna either say a procedure code or it may say CPT code.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] It's like 5 digits, 5 numbers.
[CUSTOMER][NEUTRAL] Yeah, this just says um there's a column that says claim processing codes and that's it says like a CAD 571 PPO 008 tier 02.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] You know earlier when you said that there were 4 or 5 different charges built they were set, you know, kind of separately.
[CUSTOMER][NEUTRAL] Yes, mhm.
[AGENT][NEUTRAL] OK, so is there a code?
[CUSTOMER][NEUTRAL] So there is, let me see this says um it doesn't necessarily say code but there are 5 numbers on each of these so like this one is 17,000.
[AGENT][NEUTRAL] OK. OK.
[AGENT][NEUTRAL] OK, that's the procedure code and that's a treatment code.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, give me one second.
[CUSTOMER][NEUTRAL] And then
[AGENT][NEUTRAL] So they removed something.
[AGENT][NEUTRAL] I think that's what you said earlier.
[CUSTOMER][NEGATIVE] Um, they, they froze something, not really like they didn't go and remove it, but whatever.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Uh-huh. Uh-huh.
[AGENT][NEUTRAL] Well, that's what the procedure code that you gave me, so I'm just going off of that destruction, that means a removal of something, um, and so those are treatment codes which treatment is covered, treatment in the office is covered under this policy. So generally what the provider would do is send it to your primary insurance first. They'll give them a copy of the ELB that you're looking at.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then your provider will then send us the ELB that you're looking at and then their bill, their itemized bill and then we'll process the amounts that's in that those columns and reimburse the provider those amounts.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, so basically those three columns that you, um, be applied to deductible copay and co-insurance if there's amounts in there that doesn't necessarily mean that it's gonna be paid, it's all gonna depend on the code, is that what I'm understanding?
[AGENT][NEUTRAL] It's gonna depend on if it's covered under this policy.
[AGENT][NEUTRAL] So for instance, let's say.
[CUSTOMER][NEUTRAL] So I, I wouldn't, I wouldn't know this then, right? I mean that's just something that the doctor's office is gonna have to submit to you and then you just because I just kinda wanted to get a better understanding of what am I gonna be responsible for when I go to the doctor. I thought that this policy actually picked up the difference, you know, what what was left owing.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] And it does.
[AGENT][NEUTRAL] And it does, but it has to be covered under your policy. So did you receive a copy of your policy document? Your benefits are outlined in your policy as far as what's covered.
[CUSTOMER][NEUTRAL] But what do you
[CUSTOMER][NEUTRAL] The policy for APL or another or my United Healthcare.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] You're speaking with APL, so your policy with APL.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK, so I don't think I have a copy of the policy. Is there anywhere I can go online and see that?
[AGENT][NEUTRAL] You don't? OK.
[AGENT][NEUTRAL] You can, um, you can create an online account, um, at [PII].
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Secured at.
[AGENT][POSITIVE] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] That's [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, [PII]?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then I can walk you through setting that up if you would like.
[CUSTOMER][POSITIVE] Um, I don't have time today, but I do appreciate it. Um, in this particular, um, explanation of benefits, I actually have submitted it through our, um, representative [PII], um, because I had already paid this bill, um, because they couldn't find the APL in the system, so he said that you all would be reimbursing me, um, is there any way for you to see that in the system?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] So is that an agent or is it in your your employer?
[CUSTOMER][NEUTRAL] Yes, I guess, yeah, through my employer.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so your employer should really have our, our billing information as far as claims are concerned. Um, I don't see that noted in the system when that when did they send the claim to us, do you know?
[CUSTOMER][NEUTRAL] Uh, let's see, it was through [PII], so that was on, he said it had been submitted last when was that? Oh, the [PII], OK, so that was 2 days ago.
[AGENT][NEUTRAL] On the [PII], let me see, give me a second because I do show something pending for you. Let me see what that is.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, is this for a data service of [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so I see the United Healthcare explanation of benefits.
[AGENT][NEUTRAL] Is this the one that you were going over with me just a minute ago? OK, got it.
[CUSTOMER][NEUTRAL] Yes, yes, ma'am mhm.
[AGENT][NEUTRAL] OK, so there's an office visit charge that 99213.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So the office visit fee is not covered, but the other codes.
[AGENT][NEUTRAL] Um, we can consider those treatment codes. Let me keep looking.
[AGENT][NEUTRAL] So we do need that and we should have a copy of the itemized bill from your um.
[AGENT][NEUTRAL] Medical provider.
[AGENT][NEUTRAL] So all they have sent us is a copy of the United Healthcare explanation of benefits. We'll also need a copy of the itemized bill from your doctor's office.
[CUSTOMER][NEUTRAL] Um, so I sent [PII], let me see what I sent him, and he told me it wouldn't work. Give me one second. Um, so I had the bill that they sent me from Ocala Family Medical and it had, um.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Had the office, the office visit listed on one line, um, then the destructive listed on another one and destruct the 9, so there's like 3 lines it's got those amounts on there, um, and he told me that that wouldn't work that I needed the explanation of benefits.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So this was the actual bill from the doctor's office.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And the bill that you have from the doctor's office, does it have your diagnosis code on there? The reason that you had that minor sur that surgery?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, no, it does not have that, and I believe that's why he asked me to get the explanation of benefits.
[AGENT][NEUTRAL] Or treatment.
[AGENT][NEUTRAL] OK, which we do need the ELB. Let me give you the form name. Uh, you can call your provider's office and request this form, which is an itemized bill. It'll have everything on it that we need. OK, so it's an acronym, uh, C as in Charlie, Elm Mary.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then the number 1500 15 1500 so you'll request the CMS 1500 form.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And that's an itemized bill from your provider.
[CUSTOMER][NEUTRAL] Did you say CMF or CMS?
[AGENT][NEUTRAL] Charlie Mary Sam.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK, I'll ask them for that and then is there somewhere that I can send it directly to or do I need to send it to [PII]?
[AGENT][NEUTRAL] So on your card there should be a fax number?
[CUSTOMER][POSITIVE] Yep, got it.
[AGENT][NEUTRAL] You could send it there.
[CUSTOMER][NEUTRAL] OK, all right, and your name is?
[AGENT][NEUTRAL] All right, it's [PII] A, first initial last name is [PII] You're welcome. I'm gonna go ahead and get you over a claim form, an APL claim form because we need that to accompany your documentation. Give me one second.
[CUSTOMER][POSITIVE] Thank you so much for your help.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then I'll send it to the email address that you verified and then if you can confirm that you did receive it once I send it to you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And so each time you report to a doctor or a hospital, um, in addition to your your primary explanation of benefits, we'll need the itemized bill that comes directly from that entity, whether it's a doctor's office or a hospital, so you would need to, or if you allow them to send it, they can, that might be easier.
[CUSTOMER][NEUTRAL] Mhm, OK, yeah, definitely.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] And so that may be something you just wanna communicate when you go.
[AGENT][NEUTRAL] Is that they can submit the claim to APL on your behalf.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yep, I sure will.
[AGENT][NEUTRAL] Let me get this to you.
[AGENT][NEUTRAL] And I'm sending it to [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And that was [PII] OK it's, it's so weird how S and F sometimes sound the same over the phone.
[AGENT][NEUTRAL] Mhm. [PII]
[AGENT][NEUTRAL] So [PII]. Is that correct?
[CUSTOMER][NEUTRAL] Yes ma'am mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right, just sent. I'll wait a few seconds for you receive.
[CUSTOMER][NEUTRAL] OK, it just came through.
[AGENT][NEUTRAL] It did.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And you are able to open?
[CUSTOMER][NEUTRAL] Um, let me try.
[CUSTOMER][POSITIVE] Yep got it open, thank you.
[AGENT][POSITIVE] OK, very good. Alright, anything else I can assist with today [PII]?
[CUSTOMER][POSITIVE] No ma'am thank you so much for your help you have a great day.
[AGENT][POSITIVE] Uh, you're welcome. Thanks for calling APL. Have a good day.
[CUSTOMER][POSITIVE] Thanks