AccountId: 011433970860
ContactId: ea190282-0dd0-4b45-991d-f5270df91b0b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1438839 ms
Total Talk Time (AGENT): 942120 ms
Total Talk Time (CUSTOMER): 333555 ms
Interruptions: 2
Overall Sentiment: AGENT=0.4, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/12/ea190282-0dd0-4b45-991d-f5270df91b0b_20250212T16:47_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How can I help you?
[CUSTOMER][NEUTRAL] Well, hey, [PII], it's [PII]. How are you?
[AGENT][POSITIVE] I'm doing well [PII] thank you how are you?
[CUSTOMER][NEUTRAL] I'm OK, thank you. Other than I have an insured on the line that's needing to go over.
[CUSTOMER][NEGATIVE] Several claims and the information that she has submitted. I've looked at the documents with that we received. I've gone over the comments, but she feels like we have missed.
[CUSTOMER][NEUTRAL] Something that it's already there. I mean that we have it.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, her policy number, [PII], is 1422256, and this is gonna be part two, [PII].
[CUSTOMER][NEUTRAL] And her callback number?
[CUSTOMER][NEUTRAL] It's [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] And she's referring, she's calling in regards to the last three again that we processed the [PII].
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] And [PII].
[AGENT][NEUTRAL] 13's got [PII] the [PII].
[CUSTOMER][NEUTRAL] And [PII].
[AGENT][NEUTRAL] And [PII].
[CUSTOMER][NEUTRAL] Uh-huh. Yeah.
[CUSTOMER][NEUTRAL] Uh, I
[AGENT][NEUTRAL] Yeah, I'm pulling up some documents and everybody's been everything's been verified [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Yes ma'am, she is fully she's fully verified mhm including part one's information.
[AGENT][NEUTRAL] And part two is uh who's on the line, right?
[CUSTOMER][NEGATIVE] On the line, that is correct, yes, and all these claims are for her and she thought that, you know, that we, she had gotten everything. I didn't see a diagnosis code being received. I tried to she was concerned about the um Miami Dade Fire and Rescue. I looked at that EOB of of what she sent doesn't reflect that there was anything.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Applied to the three areas. So I tried to explain that to her, but anyway.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] I think everything is correct. I didn't, you know, and I explained that she would need to, you know, contact the facility to get the diagnosis code.
[AGENT][NEUTRAL] OK, yeah, a lot of times they get the diagnosis and disease are mixed up and they think that we're asking for information, right.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And I, right, and I told her that um what I um what we received rather what I could see was a lot of procedures, things that she had had done but not a diagnosis code but anyway.
[CUSTOMER][NEUTRAL] Because those, so many of those documents started to overlap. I mean, you know, that's
[CUSTOMER][NEUTRAL] Lots of dates of service.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEGATIVE] Almost 3 claims.
[AGENT][NEUTRAL] Yeah, I'm looking at it now and that's all I see is procedures and.
[CUSTOMER][NEUTRAL] And they overlap.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] That's why it's better if they have the facility just submit on their behalf because they don't show that or deductible.
[CUSTOMER][POSITIVE] Right, and I encour mhm and I encourage them.
[CUSTOMER][NEUTRAL] On every call I take.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] To have the provider do it if they will.
[AGENT][NEUTRAL] I know.
[AGENT][NEGATIVE] Yeah, yeah, and that's one page I can't even read anything oh.
[CUSTOMER][NEUTRAL] But anyway,
[AGENT][NEUTRAL] OK, maybe that's just a duplicate of that page. I don't know I I do.
[AGENT][POSITIVE] OK, well, I'm looking at them now so you can go ahead and patch her through. I'll do my best.
[CUSTOMER][NEUTRAL] OK, [PII].
[CUSTOMER][POSITIVE] You, you always do excellent and I appreciate it. So thank you.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] All right, have a good afternoon if I don't talk to you again, OK.
[AGENT][POSITIVE] You too. You too. Thank you.
[CUSTOMER][POSITIVE] You're welcome. Bye-bye.
[AGENT][NEUTRAL] Alright bye.
[AGENT][NEUTRAL] Hello Ms. [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Hi, my name is [PII]. I'm in the claims department and Ms. [PII] transferred you over to me so I could further assist you. How are you today?
[CUSTOMER][NEUTRAL] Hi
[CUSTOMER][NEGATIVE] I'm frustrated. How are you today?
[AGENT][NEUTRAL] I, I understand, thank you. OK, so what I'm doing currently is I'm reviewing the information that was submitted for the claims uh in question and um just give me a moment to do that. I got a few pages to to review and I have to do it one at a time, so my apologies.
[CUSTOMER][NEUTRAL] OK, yeah, that.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So it looks like we were asking for some additional information uh for
[AGENT][NEUTRAL] Some services. It looks like you had some uh inpatient stay in some surgery or some type of procedure.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] OK, so initially it looks like we received the billing on that first claim submission, the 355-7830 where we asked for some additional information and what we were asking for was the explanation of benefits from your primary insurance.
[AGENT][NEUTRAL] Um, and
[CUSTOMER][NEUTRAL] OK, which, which providers or which amounts because I filed several.
[AGENT][NEUTRAL] Oh
[CUSTOMER][NEGATIVE] Um, I made several claims on the same day and I guess you guys, uh, bundle them.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So I'm not sure what amounts I'm looking at.
[AGENT][NEUTRAL] OK, so it looks like um for that again that first claim submission, the claim number 3,557,830, so it looks like there was some inpatient uh services for the radiology associates as well as Baptist Health for all those inpatient uh physicians, uh, days and then also for the uh.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Surgical procedure and then also some additional X-ray radiology uh information. Now, this uh
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] So it looks like on on that particular submission we did receive those uh.
[AGENT][NEUTRAL] Itemization of charges and that gives us the procedure codes, but we do need a diagnosis code uh in addition to the explanation of benefits. And I'm not sure um.
[AGENT][NEUTRAL] If you're aware how your policy, so this policy is uh.
[AGENT][NEUTRAL] It's, it's supplement to that major medical and it covers co-insurance and or deductible amounts for services covered under the plan, which is why it is necessary that we have the billing as well as the explanation of benefits from the primary insurance so we can show that co-insurance and or deductible that's due and then apply your benefits uh that way.
[AGENT][NEUTRAL] So initially we were asking for again no uh explanation of benefits from the primary insurance and a diagnosis code and the diagnosis code is a little different than the procedure code. Your procedure code is what services were rendered and the diagnosis code would be uh the.
[AGENT][NEUTRAL] The reason for or or that uh condition, that diagnosis code is like that condition or um you know that whether it's a sickness, illness, injury, it gives us that uh diagnosis for the services uh that were provided and the reason for that, uh, you know, with, like I said, that condition.
[AGENT][NEUTRAL] Now, um, on that additional claim for, um, for those er I'm sorry, the next claim number, the 3561393, we received the explanation of benefits, uh, from your.
[AGENT][NEUTRAL] Um, and, and again that does break down our um.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Our charges and the dates of service charges and then what was applied to coinsurance and or deductible, um.
[AGENT][NEUTRAL] However, I don't see a diagnosis code. Again, there was no diagnosis code submitted with those explanation of benefits. Now, um, can you tell me, uh, did you
[AGENT][NEUTRAL] Do you normally not present this insurance to that to those providers because usually they'll ask for your insurance information, um, and if you provide them your Aetna and this go ahead.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I,
[CUSTOMER][NEUTRAL] I, I did. I don't know why these claims weren't filed at the time, but.
[CUSTOMER][NEUTRAL] I'm sure that you're not new to
[CUSTOMER][NEGATIVE] The billing department's lack of consistency.
[AGENT][NEUTRAL] Got you, OK. Because usually that kind of solves this issue where you're not having to go because it looks like you've been back and forth with this and I can see why you're frustrated, of course, um, because it looks like uh you know, it looks like we're asking for information that's uh kind of redundant, however.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um, unfortunately that's not the case. It's like we have to have that whole picture and, and at this point it doesn't appear that that's what we have, so that's why we're kind of in the position we're in at this point, so, um.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So what do you suggest I do, [PII], go back to the hospital and ask them.
[CUSTOMER][NEUTRAL] To provide me with the diagnosis codes or?
[AGENT][NEUTRAL] Well, um, can.
[CUSTOMER][NEUTRAL] Have them refile these claims directly with you guys.
[AGENT][NEUTRAL] Well, it would be easier if they were to file the claims because they have all that information and what happens is they'll send that claim to Aetna. Aetna processes it and then sends it back to them with that explanation of benefits and because they have all those charges, um, and you know they have the, um, like I said they can reconcile um that claim information because usually what happens is they, they are.
[AGENT][NEUTRAL] Are um submitting a claim to the insurance company it's a claim form and it's what the insurance companies use for reimbursement so like I said they have that information and it's a little bit easier for them to go ahead and submit the claims on your behalf rather than have you going back and forth um.
[AGENT][NEUTRAL] And to obtain this information. Now, um, the other thing I can suggest, uh, Mrs. [PII], is that you, um, when you were discharged from the hospital, I know this looks like it was back in, in, uh, September, so, um, usually they provide you um a uh a a uh discharge summary, um, or an aftercare summary, and that would provide us with that diagnosis code.
[CUSTOMER][NEUTRAL] September
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Yeah, who know
[CUSTOMER][NEUTRAL] Yeah, I don't know if I got rid of that. I think I probably did.
[AGENT][NEUTRAL] Right, and like I said, so that, um, that would provide us that diagnosis code or again that reason for um the admission and, and, uh, you know, the uh services that were rendered. Um, so if you're able to obtain a diagnosis code, you can go ahead and submit that to us, but my suggestion would be, now, are they, are you getting bills from these uh providers, I assume.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So I guess
[CUSTOMER][NEUTRAL] Back to the providers and tell them to file a claims directly with you guys because.
[CUSTOMER][NEGATIVE] Otherwise I fear that I'm gonna be going around in circles.
[AGENT][NEUTRAL] Yeah, and, and like I said that really is the best um option is like I said if you can provide them this your, your um supplemental policy, this policy information and just tell them you have a secondary insurance but you're having uh difficulty, um, you know, getting the required information if they could just take the, uh.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] The uh information from you for this insurance and go ahead and submit a claim, then they can be paid um and usually that will you know kind of um assist them um as far as you know they wanna be reimbursed. I mean they should be sending those claims in.
[AGENT][NEUTRAL] So like I said, the other option for you would be to just obtain a diagnosis code. But like I said, in the, in the long run to have you, you know, like I said, to have you keep going back and forth. It would just be easier and it looks like um it's just the Baptist Hospital and of course, I do see where um you also had an ambulance, um.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] An ambulance ride and then also those um diagnostic services that look like they're from um.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Uh, your say as well, the radiology associates, um.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] So, um,
[CUSTOMER][NEUTRAL] I think the radio
[CUSTOMER][NEUTRAL] So see it have
[AGENT][NEUTRAL] Got it.
[CUSTOMER][NEUTRAL] Um, you know, I, I'm sorry, I'm gonna backtrack here. I, I found my final report from the hospital stay.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] But I don't see that there's a diagnostic code anywhere on here. Would it be called something else? Oh, it says.
[AGENT][NEUTRAL] Well, usually if it.
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] And it and it lists 5 different things, but there's.
[AGENT][NEUTRAL] Yeah, I, I was gonna say sometimes it may not contain a code as long as it's a description. Usually they'll say, um, you know, the discharge summary or aftercare summary, and they'll say what you were hospitalized for, you know, those conditions, and then it tells you like your next steps where to follow up with your primary care or specialist.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK. So scan that over to you.
[CUSTOMER][NEUTRAL] I have it.
[AGENT][NEUTRAL] Yeah, I would, um.
[CUSTOMER][POSITIVE] Awesome.
[CUSTOMER][NEUTRAL] boarding is a
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So now, um, also on that ambulance just so you're aware on that particular bill it does look like we uh we denied that one as the primary insurance paid in full so if there's no coinsurance and or deductible due, we won't be reimbursing for those services, so it looks like um on that uh.
[AGENT][NEUTRAL] The bill that was sent from the invoice from uh Miami-Dade Fire Rescue, it doesn't show a co-insurance and or deductible due. So it looks like they made the payment and then uh did they write off the balance because I don't see, but it does say uh balance due is 33666. So do you have an explanation of benefits from the ambulance?
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] From your primary insurance.
[CUSTOMER][NEUTRAL] You know, that was part of what I provided.
[CUSTOMER][NEUTRAL] Initially on on [PII] but for some reason.
[CUSTOMER][NEUTRAL] Wait, not, not on 128. I'm sorry, on 128 was the initial on 23.
[CUSTOMER][NEUTRAL] The
[AGENT][NEUTRAL] The 356-1393. Let me take a look at that.
[CUSTOMER][NEGATIVE] Yeah, and it says your share 0, but I don't understand.
[CUSTOMER][NEUTRAL] That
[AGENT][NEUTRAL] And now, um, in that situation as far as the Miami-Dade rescue, you may wanna contact them. I'm trying to pull up that explanation of benefits bear with me, my system's a little slow.
[AGENT][NEGATIVE] OK, it's not cooperating my apologies.
[AGENT][NEUTRAL] I'll try a different way.
[AGENT][NEUTRAL] OK, so I got it to pull up so bear with me I'm sorry.
[CUSTOMER][NEUTRAL] That's OK, the explanation.
[CUSTOMER][NEUTRAL] That they give is on page 4 I believe.
[CUSTOMER][NEUTRAL] And general remarks one.
[AGENT][NEUTRAL] Yep I see it mhm.
[AGENT][NEUTRAL] OK, so.
[AGENT][NEUTRAL] 1 and 2, let's see what that explanation reads.
[AGENT][NEUTRAL] Sometimes it's uh it's also like I said it.
[AGENT][NEUTRAL] Going through these documents like this, it's kind of hard. I mean, you really have to, you know, know what you're looking at and
[AGENT][NEUTRAL] Um, sometimes it's kind of all over the place.
[AGENT][NEUTRAL] OK, so what it's saying um that.
[AGENT][NEUTRAL] 1 and let's see, number 2. So number one, remark on that, uh, service for [PII].
[AGENT][NEUTRAL] Your provider may have sent a diagnosis.
[AGENT][NEUTRAL] OK, so from page 4 where it shows um.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Pending or not payable it shows that one.
[AGENT][NEUTRAL] Uh, remark where it has that one next to it in parentheses and it's telling us so that's where you go down to that section at the bottom of the page where it gives the explanation for 1 and then 2 so what it's saying for that number one it's saying that it was out of network basically is what that means when they give you that code and you go down and read that description for that code, it says that um.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] The provider is not part of your network. The services are considered services are considered at the in-work benefit level. Your plan covers expenses at the plan allowance in this area, uh, in this, in the area that the service was done, the amount allowed on this claim is not a contracted or agreed upon rate.
[AGENT][NEUTRAL] So what that means is they're telling us it's out of network, so I'm not certain um.
[CUSTOMER][NEUTRAL] How can how can 11 call be out of network?
[AGENT][NEUTRAL] I know.
[CUSTOMER][NEUTRAL] Not like you have much of a choice.
[AGENT][NEUTRAL] I'm sorry.
[AGENT][NEUTRAL] Well, the other thing is, is when you look on that page 4, it also says, you know, that, um, you know, it shows the amount remaining the plan shares that's the amount they pay is the 588 34, but they're saying basically that they allowed, um, they allowed that whole amount but they put it under either pending or not payable with those remarks stating that it's out of network.
[AGENT][NEUTRAL] And that's what it also says at the top under, you know, next to the provider's information it does say out of network because and what that means is that they don't participate with Aetna so that means that their fees they can charge.
[AGENT][NEUTRAL] Kind of whatever amount they want and regardless um you know, your insurance reimburse us for um what the plan would allow but in this situation it's saying it's out of network so it, it, it's basically saying that your responsibility is at 33666 and unfortunately the way we see it based on where we're at with applying your benefits under this plan.
[AGENT][NEUTRAL] It has to show coin insurance and or deductible, so that amount unfortunately is not reimbursable because we're looking at is like I said it kind of uh they they paid what what is allowed and they're not, um, so we look at it as paid in full because they allowed that amount that's what they paid but now they're saying over and above that amount is is uh.
[AGENT][NEUTRAL] Uh, out of network, so they didn't apply it to coinsurance and or deductible, they just didn't, uh, pay it.
[CUSTOMER][NEUTRAL] I, I, but by the same token on page 4, it says you're responsible for any applicable co-payment, co-insurance or deductible.
[AGENT][NEUTRAL] Right, but on the right, and it tells you though right on that line it says apply to deductible D applied to copaye they're both zero. So in other words, the amount remaining is the 58834. That's what the plan paid. However, that 33666 is saying that it's not payable based on the fact that it was out of network.
[AGENT][NEUTRAL] So in other words, like I said, if there's no coinsurance and or deductible due, this plan will not pay. So it has to be allowed by the plan and applied to the coinsurance and or your deductible in order for it to be covered under this plan with us.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Back to the other one,
[CUSTOMER][NEUTRAL] I'm gonna go ahead and send in that final report.
[CUSTOMER][POSITIVE] From the hospital and hopefully that'll clear up some other stuff.
[AGENT][NEUTRAL] Yes, like I said, because that is what um a lot of those, uh, service lines are asking for is that deductible, I'm sorry, the diagnosis code, um, and because you did send in the explanation of benefits, those those services that are uh that we've already um.
[AGENT][NEUTRAL] Uh, reviewed and, and, and ask for that diagnosis we'll go back through over those um services and, um, it should, you know, go ahead and and be applied um based on like I said, the, the fact that we do have the explanation of benefits that shows the amount now if there's any others that don't get captured, although it looks like to me that that we do have, I'm looking through.
[AGENT][NEUTRAL] The claims now and it looks like most of the services we do show the explanation of benefits so that diagnosis code again um once we have that diagnosis information we can go ahead and uh reprocess those services that were denied asking for that information.
[CUSTOMER][POSITIVE] All right, I'll I'll I'll send that in now. Thank you, [PII]. I hope you have a good day.
[AGENT][NEUTRAL] Did you have any other questions, Ms. [PII]?
[CUSTOMER][NEUTRAL] No.
[AGENT][POSITIVE] OK, thank you so much for calling APL and like I said, in the future if if you wanna try to present that um information with your Aetna, hopefully they can go ahead and sign a claim to us on your behalf, and you won't have to um kind of go back and forth.
[CUSTOMER][NEUTRAL] No
[CUSTOMER][POSITIVE] Right. OK. All right, thank you.
[AGENT][POSITIVE] OK, you're welcome. Thank you for calling APL. Have a great day.
[CUSTOMER][NEUTRAL] Bye bye.
[CUSTOMER][NEUTRAL] Bye bye.