AccountId: 011433970860
ContactId: ece34c5b-a330-4f89-9321-0e8c20f6b1d8
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1071859 ms
Total Talk Time (AGENT): 422486 ms
Total Talk Time (CUSTOMER): 254399 ms
Interruptions: 2
Overall Sentiment: AGENT=0.1, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/28/ece34c5b-a330-4f89-9321-0e8c20f6b1d8_20250428T17:48_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling American Public Life. This is [PII]. How may I assist you?
[CUSTOMER][NEGATIVE] Oh, I'm calling regarding, uh, a claim that was put in that, um, APML didn't pay anything on and I'm not sure why it's not being paid out.
[AGENT][NEUTRAL] OK, are you the policy holder or the provider?
[CUSTOMER][NEUTRAL] I'm the policy holder.
[AGENT][NEUTRAL] OK, may I have your name and a callback number?
[CUSTOMER][NEUTRAL] Um, sure, my name is [PII].
[CUSTOMER][NEUTRAL] And you can call me back at [PII].
[AGENT][NEUTRAL] And may I have your policy number?
[CUSTOMER][NEUTRAL] Policy is 02270268.
[AGENT][NEUTRAL] It's 02270268.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And your date of birth, please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And I do need to verify the mailing address and an email address. Well, we don't have an email, but your mailing address and would you like to enter an email on file?
[CUSTOMER][NEUTRAL] Um, sure, my mailing address is [PII].
[CUSTOMER][NEUTRAL] And you can add um [PII] as an email.
[AGENT][NEUTRAL] Let me make sure I have this right. [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And you're calling in regards to a claim. Do you have that date of service?
[CUSTOMER][NEGATIVE] Um, well, it's multiple dates of service between, um, March and [PII]. The claim was initially put in, um, in November and then resubmitted in December and um it's not getting anything paid on it and I don't know why.
[AGENT][NEUTRAL] OK, let me check that for you.
[AGENT][NEUTRAL] So the one that and this claim is for you for the one that was entered in or received on [PII] is showing just the date of service of [PII], is that it?
[CUSTOMER][NEUTRAL] No, it's for my wife who is on my plan. Her name is [PII].
[AGENT][NEUTRAL] OK. And her date of birth, please?
[CUSTOMER][NEUTRAL] Do you like, would you like a claim number?
[CUSTOMER][NEUTRAL] 72861.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] Yes, may I have a claim number, please?
[CUSTOMER][NEUTRAL] Sure. Um, it says 358-899-93.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] So it looks like it's requesting the primary EOB for these claims.
[CUSTOMER][NEUTRAL] Mhm but um.
[CUSTOMER][NEUTRAL] My understanding is that should have come from Florida Blue.
[CUSTOMER][NEUTRAL] And I believe it did.
[AGENT][NEUTRAL] Let me check some images.
[AGENT][NEUTRAL] OK, so for that date of service for one of the dates of service, it is showing [PII] of [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] It looks like for the claim that you submitted in is showing $522 as the bill charge.
[AGENT][NEGATIVE] But the claim that we received from the provider is only showing $6.
[CUSTOMER][NEUTRAL] Right, $6 is the amount. I, I don't think I submitted anything. Um, I went to the doctor and they submitted for Florida Blue and then they submitted for APL.
[CUSTOMER][NEGATIVE] But I don't think on my end I submitted anything.
[AGENT][NEUTRAL] Look at this. Let me look at this image because the previous one that we just processed on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It looks like that denial was for the insured submission.
[CUSTOMER][NEGATIVE] Well, I start they they were going to send me the collection, so I said started to have to pay it because I didn't want that to happen so now I'm paying for this.
[CUSTOMER][NEUTRAL] But initially when they submitted it on [PII] it came directly from APL.
[AGENT][NEUTRAL] OK, so those claims that we received in on [PII] to 25, we did deny that to the insured for the primary EOB because we did receive something from [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That was submitted into us and we were requesting the primary EOB because for the amount that she submitted in is showing 522.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And for the amount that we received from the provider is a different total. So that was the reason of saying we're needing to diag I mean the EOB because this does not match.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Well, she only submitted them because she didn't pay them, so the one from the provider is the correct one because that's the one that went through Florida Blue that got paid by Florida Blue.
[AGENT][NEUTRAL] And let me pull the image up from the provider as well.
[CUSTOMER][NEUTRAL] Right, because the provider said they submitted on [PII] and then again on [PII].
[CUSTOMER][NEGATIVE] And now I'm paying it because it's not getting paid by APL.
[AGENT][NEUTRAL] OK, so I see what she's in in.
[AGENT][NEGATIVE] So the thing is, the provider did not submit the office visit charge of the 516. They only submitted in the $6 only.
[CUSTOMER][NEUTRAL] OK, so did you pay that?
[AGENT][NEUTRAL] No, because what I'm saying is I'm from me reviewing it, that's where I'm seeing where the $552 came from compared to where the $6 came from. So the facility did submit in $6.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And it shows for some reason that one was denied, but I'm gonna send that one back to the the examiner, but the reason that the one that [PII] sent in was denied for the EOB because they didn't match with the total bill.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right, well, that, that's from [PII]. There, there's also service from 314 and [PII] and 620.
[AGENT][NEUTRAL] So,
[AGENT][POSITIVE] Yes, I'm ready to look at that one as well.
[AGENT][NEUTRAL] And I'm gonna highlight this information.
[AGENT][NEUTRAL] Then the next day is [PII].
[AGENT][NEGATIVE] Now for the data service of [PII] we never did receive a facility bill for that data service so that one did denied for the EOB because we don't have one on file at all.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, I'm on my Florida blue right now and I guess I could go claim by claim and download it and send it to you. Is that the best way to process this because I, I don't wanna continue paying.
[CUSTOMER][NEUTRAL] You know, for something I'm insured for.
[AGENT][NEUTRAL] Yes, you can yes you can submit that EOB and we we need it for date of service [PII].
[AGENT][NEUTRAL] For that claim number.
[CUSTOMER][NEUTRAL] Um, 6:13.
[AGENT][NEUTRAL] OK, 6:13 is not on that claim number, so you have a different claim number as well?
[CUSTOMER][NEUTRAL] Uh, no, that's the only claim I have, but I have services on 383-14613 620628, 712 719, and 89.
[AGENT][NEUTRAL] OK, so have those services been submitted in?
[AGENT][NEUTRAL] And we denied them or
[CUSTOMER][NEUTRAL] Yes, well, they told me they've submitted everything.
[AGENT][NEUTRAL] OK, so do you have any other claim numbers other than the one that you just gave me to review?
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] OK, and it was 3:14. Let me see if we have that claim.
[CUSTOMER][NEUTRAL] I
[AGENT][NEGATIVE] So I'm pulling up the claim for 314. Now for the claim for 314 date of service, that claim did process and it shows that that claim denied.
[AGENT][NEUTRAL] Due to we do not for a facility, we do not cover anything rented for an office setting.
[CUSTOMER][NEUTRAL] I'm sorry, what?
[AGENT][NEGATIVE] For for this being a facility bill, we do not.
[AGENT][NEUTRAL] Cover anything rendered for an office setting in a hospital facility.
[AGENT][NEUTRAL] So they build it, go ahead.
[CUSTOMER][NEUTRAL] Well, it, it's not a hospital facility.
[AGENT][NEUTRAL] Yes, for the data service of 314, the facility bill that we received in is from Boca Raton Regional Hospital. So that is the facility, and since they submitted it in for that procedure rendered within an office setting, that is not a covered benefit under this policy for your facility.
[CUSTOMER][NEUTRAL] So what would I need to do? I didn't go to the hospital.
[CUSTOMER][NEUTRAL] I just went to a doctor.
[CUSTOMER][NEUTRAL] So and I can't control how they're they're billing.
[AGENT][NEUTRAL] Is this for you or for [PII]?
[CUSTOMER][NEUTRAL] Well, it's for my wife [PII].
[AGENT][NEUTRAL] OK, so it's the facility submitted.
[CUSTOMER][NEUTRAL] We're the same if I say I, I mean her.
[AGENT][NEUTRAL] OK, but the facility submitted in a bill where you went to the facility and that is [PII].
[AGENT][NEUTRAL] On [PII].
[CUSTOMER][NEUTRAL] Yeah, it was in [PII], but it's not a hospital.
[AGENT][NEUTRAL] They submitted it in for the hospital. So, apparently that's the only way that they submit a bill. They don't submit it in as a physician office.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So there's nothing I could do.
[AGENT][NEUTRAL] You would have to discuss with them on how they submit their bills because the way that we received it this is a facility.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK, so there's a different bill here that, uh, but there it's all the same then if that's the.
[CUSTOMER][NEUTRAL] The claim provider they're billing it under.
[AGENT][NEUTRAL] Yes, if, if we did receive it and they did submit it in for an office setting on a facility, we do not cover that.
[CUSTOMER][NEUTRAL] Is what you're telling me, right?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, alright, so I'll reach back out to them.
[AGENT][NEUTRAL] And then I think it it's another date for that claim that you were talking about the previous claim, so we did, I did say that we did need it for [PII] but then also for the [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I'm gonna pull that image up and if it needs to be submitted back to that examiner.
[AGENT][NEUTRAL] I'm gonna have them to pull that one as well.
[AGENT][NEUTRAL] Let me pull that up.
[AGENT][NEUTRAL] And so then the [PII]:12, I'm gonna have that examiner to review this one as well.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And just have them to review it. Now it's not a guarantee that it will be reprocessed as payable, but I will send this back for them to examine it, to review it as well to see.
[AGENT][NEUTRAL] But you do have a right to submit in any type of form of appeal if you would like if you do not agree with any of these claims.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm and how do I submit that appeal?
[AGENT][NEUTRAL] So for submitting of the appeal, you would have to submit the documentation or the date of service that you're requesting to be reviewed as an appeal, and you will have to either just state that you would like for us to review or do a reconsideration of the claim.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEGATIVE] I'm sorry, you're breaking up.
[AGENT][POSITIVE] Oh, apologize for that. OK.
[CUSTOMER][NEUTRAL] Ho hold on. I, you're breaking up a little bit. I can't hear you.
[AGENT][NEUTRAL] OK, so any claim that you or date of service that you have for us to review, you would have to document that and indicate which date of service or total amount.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] And then you would also have to submit in that documentation which is the EOB in order for us to review it as well and just put something on there stating that you would like for this to be a reconsideration or appeal.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, and where do I do this uh meeting?
[AGENT][NEUTRAL] You can submit it either to the secured portal.
[AGENT][NEUTRAL] Fax or mail it in.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, let me see if I have a fax number on this documentation.
[CUSTOMER][NEUTRAL] I have a website I don't have um.
[CUSTOMER][NEUTRAL] A fax number though let me get a fax number.
[AGENT][NEUTRAL] OK, the fax number would be?
[CUSTOMER][POSITIVE] I'm ready when you have it.
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII] and that is attention claims department.
[CUSTOMER][POSITIVE] OK, great.
[CUSTOMER][POSITIVE] Alright, I'll see what I could do with this.
[AGENT][NEUTRAL] And is there anything else I can assist you with today, Miss [PII]?
[CUSTOMER][POSITIVE] No, that's it thank you very much.
[AGENT][POSITIVE] You're welcome. Thank you for calling American Public Life. Have a great day.
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][POSITIVE] Thank you bye.