AccountId: 011433970860
ContactId: ea6fb41d-7d0a-4d56-bc3f-ae0c67b0179d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 838940 ms
Total Talk Time (AGENT): 384942 ms
Total Talk Time (CUSTOMER): 398514 ms
Interruptions: 0
Overall Sentiment: AGENT=-0.1, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2024/12/30/ea6fb41d-7d0a-4d56-bc3f-ae0c67b0179d_20241230T15:15_UTC.wav
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[AGENT][NEUTRAL] Calling APL, my name is [PII]. How may I assist you today?
[CUSTOMER][NEUTRAL] Hi, yes, I have a couple of questions for you. Um, I, I didn't realize I have a gap insurance until fairly recently.
[CUSTOMER][NEUTRAL] And I was wondering if you could help me figure out how to get um put in the claim for other um things that I've had done this year so that I can help pay my medical bills.
[AGENT][NEUTRAL] OK, I'd be happy to assist with uh information on filing claims. Um, may I have your first name please?
[CUSTOMER][NEUTRAL] First name is [PII]
[AGENT][POSITIVE] And [PII], if I can get a good call back number for you.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And what is your policy number?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] There's 2. One's an in-hospital benefit and one's an outpatient benefit.
[AGENT][NEUTRAL] It doesn't matter.
[CUSTOMER][NEUTRAL] Um, OK, 02241482 M as in Mary, L as in Larry 7.
[CUSTOMER][NEUTRAL] The other one is the same, it just has an 8 at the end.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And if you can verify your last name, date of birth, and email address.
[CUSTOMER][NEUTRAL] Sure. Last name is [PII] My birthday is [PII] and email is [PII] or [PII].
[AGENT][NEUTRAL] OK, we have the latter.
[AGENT][NEUTRAL] Is that fine?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, that's my, my work email.
[AGENT][NEUTRAL] OK, OK.
[AGENT][POSITIVE] Alright, thank you for that information.
[AGENT][NEUTRAL] OK, now are you registered with the online service center?
[CUSTOMER][NEUTRAL] I'm not sure. I, I didn't even, I literally didn't know I had this, so where can I get that?
[AGENT][NEUTRAL] OK, so you're probably not. OK, um, so, well, first let me ask you how do you want it because that's um one of the ways you can submit the claim is after you register you can upload the information online or you can mail it or fax it in.
[AGENT][NEUTRAL] Um, but that's the easiest is to upload it, right? OK.
[CUSTOMER][POSITIVE] It's probably easier to upload.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um, so once you have, um, set up your account online and it's at [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] You're gonna use that email address that you just gave me because that's the one that we have on file.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] So once you um set up your account then it'll allow you to submit your paperwork. Now the paperwork that we need to pay the claim.
[AGENT][NEUTRAL] Is the explanation of benefits for each data service that you're filing for from your major medical company. So who's your major medical?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] UnitedHealthcare.
[AGENT][NEUTRAL] OK, so you would go to United Healthcare and they probably more than likely have it where you can access your EOB they call it EOBs, your EOBs online, so for each data service you're claiming, we'll need that explanation of benefits.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, we'll also need the medical diagnosis for each, um, visit.
[CUSTOMER][NEUTRAL] OK, how do I get that?
[AGENT][NEUTRAL] So you'll, from whoever provided the medical services. So if you're filing for an ER visit, you can contact the hospital and let them know you need your diagnosis information because you're filing with your gap insurance.
[CUSTOMER][NEUTRAL] OK, so maybe I can, can I, I wonder if I can get that through the, the, the hospital app.
[AGENT][NEUTRAL] Like on my chart?
[CUSTOMER][NEUTRAL] Um, yeah, well, I'm not, see, I don't know. I've, I've got two different diagnoses from two different, um, doctors, so I wanna make sure that I'm.
[CUSTOMER][POSITIVE] I'm getting the right things, you know what I mean?
[CUSTOMER][NEUTRAL] Cause I don't know that I have everything online from both doctors.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I mean one if it's the same data service, one diagnosis is fine. We just need a diagnosis and an EOB for the data service that you're filing.
[CUSTOMER][NEUTRAL] OK, yeah, no, I, I don't.
[AGENT][NEUTRAL] So just make sure you have those two pieces of information. If you don't, if we're missing something, if you only send in the EOB, the claim will deny and we're gonna ask you for the diagnosis code.
[AGENT][NEUTRAL] If you send in just medical information or with the diagnosis and no EOB we're gonna deny it and ask for the EOB.
[CUSTOMER][NEUTRAL] OK, so I need to
[CUSTOMER][NEUTRAL] OK, so diagnostic results. Let me see if, because I have diagnostic results from, from my breast doctor who is not the same as the person who was my under my um gastroenterologist. So, so I need to give you the, the diagnosis from my, my end my, my gastroenterologist to justify the diagnosis of what I had done from that point on, or does that diagnosis have to go with everything?
[AGENT][NEGATIVE] No, no, no, no, no.
[AGENT][NEUTRAL] When we say we want the diagnosis, say you went and got um
[AGENT][NEUTRAL] A diagnostic breast ultrasound. We just need paperwork saying the diagnosis for that data, for that test is whatever the diagnosis is. We don't need a whole lot of diagnosis or this diagnosis must justify that one. We just need a diagnosis for that particular data service.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right, but so I had, OK, give you, let me give you an example. I had a um.
[CUSTOMER][NEUTRAL] Um, a breast MRI biopsy.
[CUSTOMER][NEUTRAL] Is that something that I need to get the diagnosis from?
[CUSTOMER][NEUTRAL] And submit with the with the claim because that's leading to other issues that I'm gonna have in February done to me so that I can get rid of it, do you understand?
[AGENT][NEUTRAL] Right. So,
[AGENT][NEUTRAL] When, when they put in the order for your MRI, either the results of that MRI will have a diagnosis or the order will have the diagnosis.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so I'm gonna have to call, OK, because I have two different.
[CUSTOMER][NEUTRAL] Um, I'm, I'm with, I, I went to [PII] for one thing that was with my gastroenterologist, and I went to, um, the Miami Breast Institute for my breast, um, diagnosis. So I need to get both of those. So, like, for example, I had, I had a colonoscopy on [PII], but it was my third colonoscopy because they found a neuroendocrine tumor. And then on the
[CUSTOMER][NEUTRAL] Back in September. And then in um
[CUSTOMER][NEUTRAL] In the [PII] they did surgery to remove that portion. And so I gave them my gap card for the [PII] surgery, but I don't know if it was.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] If it was accepted or denied or whatever however you call it because the, the lady told me I'm charging your credit card this much money and if the gap insurance is approved, they'll take $200 off and I was like, OK, but then it, I got the bill and it didn't take the $200 off. Is there a way that you can check that to see if that maybe was denied?
[AGENT][NEUTRAL] Well, I'm not sure we've had any claims from from you since we you've had coverage with us so nobody's filed with us.
[CUSTOMER][NEUTRAL] Really? Because I gave them my card on the on the [PII] and then she brought it back to me.
[AGENT][NEUTRAL] Now, remember, because with your gap, we work 2. Everything has to go first to your primary insurance and then they would bill us. So they may not have, if you just had, was treated on the [PII], I highly doubt that that claim was processed, sent back to the provider in, in enough time for them to send it to us.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. So, all right, that leads me to the next question I have. Um, so I did a colonoscopy for the very first time in my life in September. And in that colonoscopy, they found a neuroendocrine tumor in um in my small intestine area. Um, and they said that I could live with this for the next 20 years, but then in 20 years, it'll be problematic and it'll become cancer and I would have a lot of situations that were, were bad.
[CUSTOMER][NEUTRAL] So they recommended that I, I do, um, I had to have a second colonoscopy because the first pathology showed that I didn't, he didn't get all of the, the, the bad cells.
[CUSTOMER][NEGATIVE] So I went back in 1 week and a half or 2 weeks later and had a second colonoscopy done and um was charged by my insurance company for that. And then it, you know, throughout all of this, I find out that I have gap insurance. So I didn't even know that I had this option. Um, so I have to go back now and submit.
[CUSTOMER][NEUTRAL] My original diagnosis from the original um colonoscopy along with the medical explanation of benefits for the second one. Is that what you're telling me?
[AGENT][NEUTRAL] I don't know, I guess I'm getting confused myself, um.
[CUSTOMER][NEGATIVE] I know, see it's where I'm like, I'm so lost.
[AGENT][NEUTRAL] So they send you paperwork from each procedure that you have and they explain what they did and what they found.
[AGENT][NEUTRAL] We just need the diagnosis from each procedure.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] I, I just don't know how else to.
[CUSTOMER][NEUTRAL] OK, so what, what I'm gonna have then is I'm gonna have uh the results from my first colonoscopy, the results from my second colonoscopy, and then um.
[CUSTOMER][NEUTRAL] I'm just gonna send everything that has to do with the, the colonoscopies and the surgery that I had in one email that way it's all together and then I'm gonna, cause I've had.
[CUSTOMER][NEUTRAL] I had a second colonoscopy done, um, two weeks after the first one back in September and then I had to do another colonoscopy for the surgeon to be able to locate where it is on [PII] and then [PII] with the surgery where he went in and took out that portion, um, so that I would be rid of it and, and, and able to be fine for the, you know, in that area for, God willing, ever.
[AGENT][NEGATIVE] OK, so here's what I don't want to happen, Miss [PII]. I do not want you to bunch everything and send it and then start getting denials because.
[CUSTOMER][NEUTRAL] So what if you
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] You send in a diagnosis for [PII], but we have an EOB for [PII] cause we're gonna deny.
[AGENT][NEUTRAL] You see how the, the date need to match up the diagnosis dates need to match up with the EOB dates. So if you, you jumble everything together and send it in, it increases the chances of something being mistrans it just, it can just cause confusion. I, I just don't want you to start getting denials and get frustrated, so I'm trying to explain.
[CUSTOMER][NEUTRAL] OK, but I can
[CUSTOMER][NEUTRAL] The date must match. OK.
[AGENT][POSITIVE] The fastest way to get the claim paid.
[CUSTOMER][NEUTRAL] OK, so I, I need to
[AGENT][NEUTRAL] We need a you went in on the [PII]. If you have paperwork and diagnosis saying, hey, we did a colonoscopy on the [PII] and we found colon polyps. That's a diagnosis. And then you have the EOB where UnitedHealthcare said, hey, we got a claim for
[AGENT][NEUTRAL] Your colonoscopy and here's what your patient responsibility is put those two together and upload them because those are the two pieces of information we need to pay the claim, but don't mix and match because the diagnosis from the [PII] is not gonna pay the claim for the [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, OK, so I need to submit, yeah, so I need to submit the, the, each, each procedure.
[AGENT][NEUTRAL] Does that make sense?
[CUSTOMER][NEUTRAL] With matching dates.
[AGENT][NEGATIVE] Each procedure with matching dates and diagnosis. Other than that, the claims are gonna deny and it's gonna be a frustrating process.
[CUSTOMER][POSITIVE] Good good to know. OK, this helps this helps. I can, I can start gathering this information because I believe I have everything.
[CUSTOMER][POSITIVE] I think I have everything online accessible to to me through my my patient portal in different various places and if I don't, I'll I'll ask the other places to OK all right this this helps this helps me kind of organize my, my thoughts and my and my documents so that I can submit everything um individually based on matching dates. OK, that helps.
[AGENT][NEUTRAL] Right, and, and for faster service if you upload each one, so say you have 5 dates of service you wanna get that $200 benefit for.
[AGENT][NEUTRAL] Upload them separate.
[AGENT][NEUTRAL] Cause we'll combine it, but it makes it for easier reading when processing because I've seen times where the diagnosis for one was on, on this upload, but then on another upload the information, the EOB for that diagnosis was on a different.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, mail number or you know upload number and it was overlooked or missed.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, OK, OK, I, I get it. I get what you're telling me just make, make.
[AGENT][NEUTRAL] So just everything.
[AGENT][NEUTRAL] I got my data service [PII]. I have my diagnosis and my EOB since [PII]. That's one claim I'm gonna upload that. I got [PII]. I got my diagnosis and my EOB for that. I'm gonna upload that together. That's a separate claim. Even if you upload 5 separate ones, we can, we can merge all that mail together and pay out one payment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, that helps. Now for the, yes, so then um I need to be, I need to wait until I get my
[AGENT][NEUTRAL] Does that make sense?
[AGENT][NEUTRAL] Did I lose you or confuse you?
[CUSTOMER][NEUTRAL] No, I'm here.
[CUSTOMER][POSITIVE] No, no, no, so far so good, so far so good. I, I think I'm here. Can you not hear me?
[AGENT][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] Are you there?
[AGENT][NEUTRAL] Hello Ms. [PII], are you still there?
[CUSTOMER][NEUTRAL] Yes, I'm here.
[CUSTOMER][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] I'm here. Can you hear me?
[CUSTOMER][NEUTRAL] I'm here.
[AGENT][NEGATIVE] OK, I'll need to disconnect for no response.
[CUSTOMER][NEUTRAL] Oh, I hear you.