AccountId: 011433970860
ContactId: e983ad20-98b9-49d0-985f-b33f62f42135
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1199359 ms
Total Talk Time (AGENT): 541083 ms
Total Talk Time (CUSTOMER): 549498 ms
Interruptions: 4
Overall Sentiment: AGENT=0.6, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/09/e983ad20-98b9-49d0-985f-b33f62f42135_20250109T21:43_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling AL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. I'm calling.
[CUSTOMER][NEUTRAL] Uh, just to get some help. Um, I have a policy through my work. I'm a teacher and I had a bunch of medical stuff recently and, um, I'm just not quite sure how to go about.
[CUSTOMER][NEUTRAL] Uh, filing a claim.
[AGENT][POSITIVE] OK, absolutely. I'm happy to help with that. Do you by chance have your policy number? we can start there?
[CUSTOMER][NEUTRAL] I should.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Yes, it's 20,860.
[AGENT][NEUTRAL] Alright, let me pull this up here one second.
[AGENT][NEUTRAL] Alright, do you have by chance the card in front of you?
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Because the 20,860 doesn't come up, but I can search by your name or social if I need to.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Um, yeah, maybe that would be better. I'm not sure if I have the card or not, but if we can search by name or social, that'd be great.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, yeah, whichever you prefer to give me, go ahead whenever you're ready.
[CUSTOMER][NEUTRAL] OK. Let's start with my name. Um name is [PII]
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Middle name is [PII] and then last name is [PII]
[AGENT][POSITIVE] Alright, thank you, [PII]. 1 2nd.
[CUSTOMER][NEUTRAL] Uh huh.
[AGENT][NEUTRAL] What state do you live in?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII], OK.
[AGENT][NEUTRAL] And then if I could verify, what is your date of birth?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Alright thank you so much [PII] I think I found you here. I just need to lastly verify the address we should have on file.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Uh, no problem. It is [PII].
[AGENT][POSITIVE] All right, thanks so much. OK.
[CUSTOMER][NEUTRAL] All right.
[AGENT][NEUTRAL] So the plan that you have with us is like a secondary a gap insurance um to cover anything that, you know, your primary doesn't.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So there's one of two ways that you can do this. Um, if you've already had, I think you had said um in the past.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Um, some procedures or stuff done that, um, you still owe on, you can contact those providers and let them know that you have the secondary insurance and that um the residual remaining they can bill to us, or you can file the claim yourself and what you would need to do that online would be.
[AGENT][NEUTRAL] A claim form from us.
[CUSTOMER][NEUTRAL] Like
[CUSTOMER][NEUTRAL] Yes, so.
[AGENT][NEUTRAL] And then you would need the explanation of benefits from your primary insurance.
[CUSTOMER][NEUTRAL] So the, OK, so I talked to my um.
[CUSTOMER][NEUTRAL] The people who I guess my insurance provider um through school, my, my agent or whatever, [PII], [PII], um, through Walker Insurance, and she gave me, um the she email emailed me um the form and then she also on that form there's a link to the um.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] To the online my coverage upload.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] My questions are, um, so I have Blue Cross Blue Shield is my primary.
[CUSTOMER][NEUTRAL] And they have an app that or a website that basically outlines every single claim that's been made.
[CUSTOMER][NEUTRAL] And um.
[CUSTOMER][NEUTRAL] Like what's what's been billed and what's been
[CUSTOMER][NEUTRAL] Um, covered, I guess, um.
[CUSTOMER][NEUTRAL] Hold on, let me, let me bring it up and I'll so like for instance University of Texas Southwestern, it says claim total 158. My responsibility is 70, and it shows it's partially paid. It has a claim number and everything. My question is the explanation of benefits, what exactly is that? And it are these claims that are on my Blue Cross Blue Shield website, um.
[CUSTOMER][NEUTRAL] Am I able to get that information from that?
[AGENT][NEUTRAL] Yes, so they should be able to provide you that so it's kind of like what you're talking about. I don't know if on their app or their site there so like for that specific one that you were talking about like that date of service, is there any sort of link there to like a um PDF file yeah for an EOB.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes, and EOB.
[AGENT][NEUTRAL] So that's what
[CUSTOMER][NEUTRAL] I do have that, yup.
[AGENT][NEUTRAL] Yeah, so that's what you would want to submit with the claim form because that's showing us that you went to provider XYZ Blue Cross Blue Shield paid X amount of dollars, and then it shows us the remaining amount and what you were seeing for.
[CUSTOMER][NEUTRAL] OK, next question, uh, the ones the claims that are completed would be useless essentially because there's nothing to pay on those?
[AGENT][NEUTRAL] If there's, yeah, I mean if there's um.
[AGENT][NEUTRAL] Nothing
[CUSTOMER][NEUTRAL] Or or or are you refunding me? So I, if I showed you that it would help toward.
[CUSTOMER][NEUTRAL] Forward your what you need to to pay me, is that the second option when you said um I can file the claims myself, is that where you would just like like cut me a check basically? Is that how that works?
[AGENT][NEUTRAL] Right, exactly. So yeah, if you have a claim that's completed and let's say it was just for like treatment in an office or something like that and you paid the copayer, you know, the full amount, there's nothing remaining, you can still submit that claim for reimbursement from us.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and then, um, my max, um, allowable back from you is that 2500?
[AGENT][NEUTRAL] Um, let's see.
[CUSTOMER][NEUTRAL] Or their ma
[AGENT][NEUTRAL] So your outpatient benefit amount on this is $500 per occurrence. What that means is that the max the plan will pay out is $500 outpatient being seen for the exact same thing. That's what per occurrence means.
[CUSTOMER][NEGATIVE] OK, so that's the $500 I, I'm so confused.
[CUSTOMER][NEUTRAL] Um, I don't even know where to start like.
[AGENT][NEUTRAL] So the inpatient is 2500.
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] OK, I have literally, uh, I think it's.
[CUSTOMER][NEUTRAL] Uh, I have 12345678.
[CUSTOMER][NEUTRAL] I have about 70 claims here.
[CUSTOMER][NEUTRAL] For the year.
[CUSTOMER][NEUTRAL] I have a lot cause um.
[CUSTOMER][NEUTRAL] I ended up having a tumor removed and then I ended up having a bunch of complications after so.
[CUSTOMER][NEGATIVE] Like, I don't even know, like, do I mean I have got claims here that are $100,000. I've got one for $14,147,000 then I've got, you know, some for $38. Do I do I send every single one of these EOBs in? I mean, I don't even.
[CUSTOMER][NEUTRAL] Or would the whole policy basically be wiped out with the 100K claim?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so yeah, this is what you could do. So inpatient is defined. That's where your 2500 amount comes from. So inpatient definition means that you had to be in the hospital for 18 continuous hours.
[CUSTOMER][NEUTRAL] I'm just
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So that's for your 250.
[CUSTOMER][NEUTRAL] Whether that was a scheduled surgery, whether that, sorry, I'm sorry to cut you off, whether that was a scheduled surgery or whether that was an emergency visit doesn't matter, just 18 hours, OK.
[AGENT][POSITIVE] Correct. Correct.
[AGENT][NEUTRAL] So, the 2500 would fall under that. So, like you said, you had to have a surgery, you're in the hospital. So what you could do is take the largest one that you have that your responsibility is for that was considered quote unquote inpatient cause you were in the hos, you know, being treated for over 18 hours in the hospital.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] You could just submit one or two to start with your larger ones for the inpatient wait a few days, let those process out and see if it wipes out your benefit max for the year.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Got it OK.
[AGENT][NEGATIVE] And then if it doesn't, you could then go back that way you're not submitting just 70 and you know what I mean, and wasting all that time.
[CUSTOMER][NEUTRAL] Yes, yes.
[CUSTOMER][NEUTRAL] And is there a way I can get a ballpark of what it will, what it will, um, basically eat into my, um, 2500 is it but basically will your responsibility number be, um.
[CUSTOMER][NEUTRAL] How to calculate like how fast that $2500 gets used.
[CUSTOMER][NEUTRAL] If you know what I'm saying.
[AGENT][NEUTRAL] I don't know if I'm under I don't know if I'm understanding the question, [PII]. I'm sorry.
[CUSTOMER][NEUTRAL] OK, let me, no, it's me for sure. Uh, let me go see, uh, real quick on one of these larger ones, uh, OK, here's the $100,000.01 explanation benefits.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Yes, OK, so amount billed was 100,000 and then it says discounts and reductions 100,000 and then it says you may owe your health care providers zero, so they knocked all that out, right? So I wouldn't even be able to submit that to y'all, is that correct?
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Yeah, I mean if you're primary paid the full amount there's yeah there's nothing to be reimbursed them from us on that one that would be correct.
[CUSTOMER][NEUTRAL] OK, um.
[CUSTOMER][NEUTRAL] So there's one just for instance that was uh.
[CUSTOMER][NEUTRAL] 8,352 and then it says 787 is my responsibility. um this is an anesthesia partner that was that was part of that hospital stay. Would that be claimable?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm. Absolutely.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So basically should I just try to add up the the your responsibility um numbers until I get to around 2500 and then stop there and see what comes back.
[AGENT][POSITIVE] That's what I would do absolutely and then because there's no time frame on filing these so uh then you could uh get a response back on those and see what the benefit payments are and then if you have some additional ones then file those at that time, yeah for sure.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] But essentially when I go to my EOB page I need to see that I owe something or I paid something for you for you guys to come into the picture.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK and then um on the um outpatient um per occurrence, what do you mean for like.
[CUSTOMER][NEUTRAL] Can you give me um like I've got uh I've got referral I've got office for referral fees I've got office fees I've got.
[CUSTOMER][NEUTRAL] Um, basically, that's what my outpatient.
[CUSTOMER][NEUTRAL] Would consist of, I think.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] So the only thing that your plan's not.
[CUSTOMER][NEUTRAL] I've got pathology.
[AGENT][NEUTRAL] OK, yeah, your, your plan isn't gonna cover any sort of office visit fee.
[AGENT][NEUTRAL] Um, it does cover like treatment in a physician's office, but the office visit fee itself is not covered under the plan.
[CUSTOMER][NEUTRAL] What about like a pathology charge?
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Mhm. Yeah.
[CUSTOMER][NEUTRAL] That's that would be in an in an outpatient.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, um, and you're saying that go ahead.
[AGENT][NEUTRAL] So they
[AGENT][NEUTRAL] Go ahead.
[AGENT][NEUTRAL] I was gonna say they defined, they defined per occurrence as this. So per occurrence means treatment for the same or related condition unless separated by 90 days. So an occurrence would be I broke my arm and I'm receiving treatment for the broken arm.
[CUSTOMER][POSITIVE] I'm sorry
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] I'm only going to be paid out a maximum outpatient of $500 for that broken arm. Now, if something happens, let's say in 6 months goes by and now have a difficulty from the broken arm, that's now a new occurrence.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I understand now um.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then the last question I think I have is when I go online, so I I um go to my Blue Blue Cross Blue Shield and I click on the EOB link and it takes me to that page if I just download that, do I then just upload that um to your uh claim process and then that's essentially how I would submit that?
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Yep, absolutely that's honestly easiest way to do it if if you're comfortable doing that, yep.
[CUSTOMER][NEUTRAL] Oh, OK, and then, um.
[CUSTOMER][NEUTRAL] How do I differentiate between inpatient and outpatient?
[CUSTOMER][NEUTRAL] Or do I just upload and you'll figure that out?
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] Yeah, so as far as the benefit payments go, it'll it'll pay towards whichever bucket, um, the claims examiner will differentiate that so you don't have to worry about that.
[CUSTOMER][NEUTRAL] OK, so when I go to this um this page it has a green, um, hyper uh link that says upload files and it has one policy number.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Um, it doesn't really have anything about a claim number or anything. I just basically start uploading all those EOBs and just see where the chips fall.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So yeah, you'll click upload files and then you'll do, you can only do the the download or upload can only be so many megabytes so um you may have to do like if you're gonna do 3 or 4, you may have to do each one individually you may not be able to do them all at once because of the size of the file.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Once you submit it, you'll get a confirmation from the online service center like a confirmation number.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Does every time I submit an EOB file um.
[CUSTOMER][NEUTRAL] Does it, does it create a new like a new case number for each EOB or does it even give me a case number because it's just asking me for inter claim details which basically I'm picking the applicant because there's two, there's me and my dependent.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] And then it just says upload documents.
[CUSTOMER][NEUTRAL] And then
[CUSTOMER][NEUTRAL] Uh, and there's a complete button, but I haven't uploaded anything yet, so I don't know what that looks like, but.
[CUSTOMER][NEUTRAL] I'm essentially just.
[AGENT][NEUTRAL] So once you click.
[AGENT][NEUTRAL] Complete it would then assign you like the confirmation and then a claim number, so that would be completing it.
[CUSTOMER][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then the next, the next file I upload, um, would, would basically produce a new claim number.
[AGENT][POSITIVE] Uh-huh. Correct.
[CUSTOMER][NEUTRAL] OK, so really this isn't that hard essentially as far as what I'm doing I'm just downloading and then uploading.
[AGENT][POSITIVE] Yeah, absolutely. And it just, um, like I said, just takes a little bit of time and, and some patience is all, uh, to do it, is all.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And, and do you does your um.
[CUSTOMER][NEUTRAL] And what, what, what the person that looks at this, what, what did you, what was their title again?
[AGENT][NEUTRAL] Oh, they're a claims examiner.
[CUSTOMER][NEUTRAL] Yeah, claims examiner, I mean if I just if I just uploaded every single EOB I had, I mean, would that be.
[CUSTOMER][NEUTRAL] Would that be an overkill or you know, um, or can I do that? Would that be OK?
[AGENT][NEUTRAL] I mean you can do like I said there is a limit as far as um the megabytes as far as what you can upload so I don't know that the system would even allow you to do that many because the file would be so large.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, if you wanna take the time to do all of them that you have, I mean you can absolutely do that, it just may take longer for them to process the claim.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Cause they're gonna have to.
[CUSTOMER][NEUTRAL] But they'll let me know as they.
[CUSTOMER][NEUTRAL] They're gonna have to like go through them all to see which which ones apply it uh as I go if I just did a few, um, would I be updated as far as as as how much I have left um in my payout?
[AGENT][NEUTRAL] Right, right. Right.
[AGENT][NEUTRAL] Um, yeah, I mean, so you'll, you'll definitely get a status update once the claim has been processed and then through the portal you can see the benefit payment and so um it's not gonna show you left amount remaining but if you know what the amounts are and you can honestly check with us if you want us to and we can give you the amount paid to date.
[CUSTOMER][NEUTRAL] Like the remain
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK perfect and and last question uh is there a place to upload banking information or is it all paper pay?
[AGENT][NEUTRAL] Um, no, you should have an option in there to, let's see, upload your bank information. Let's see.
[AGENT][NEUTRAL] Um, in the top right hand corner, yeah go to payment preferences and you can put in your routing and account number there, um, don't be alarmed, there is, um, sometimes with the routing and account number it will show a different bank name.
[CUSTOMER][NEUTRAL] Payment preferences.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So just make sure that you're verifying your routing and account number and as long as all that's right you shouldn't have any issues with the payments.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK perfect well hey thank you so much sir I appreciate you and um.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah I guess I'll be.
[CUSTOMER][NEUTRAL] Seeing what what I can do here.
[AGENT][POSITIVE] All right [PII], yeah, if you think of anything else feel free to give us a call that's what we're here for.
[CUSTOMER][POSITIVE] OK, thank you so much.
[AGENT][POSITIVE] You're welcome. Have a good day.
[CUSTOMER][POSITIVE] All right you too bye bye.
[AGENT][NEUTRAL] Bye-bye.