AccountId: 011433970860
ContactId: eceaf784-f3e2-45c4-8c1d-d92a9ccf8ba0
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 972849 ms
Total Talk Time (AGENT): 425033 ms
Total Talk Time (CUSTOMER): 514451 ms
Interruptions: 14
Overall Sentiment: AGENT=0.2, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/02/eceaf784-f3e2-45c4-8c1d-d92a9ccf8ba0_20250602T18:41_UTC.wav
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[AGENT][NEUTRAL] Calling APL. my name is [PII]. How can I assist you today?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Hi, [PII]. Um, my name is [PII]. I'm calling um in regard to a couple of these bills that keep coming to me even after I gave my gap insurance to the places that I had gone to.
[AGENT][NEUTRAL] It
[CUSTOMER][NEGATIVE] And I'm wondering why it's not covered or why they keep sending me these bills.
[AGENT][POSITIVE] I'd be happy to assist. May I have your policy number, please?
[CUSTOMER][NEUTRAL] Uh, yeah, give me one sec.
[CUSTOMER][NEUTRAL] Can I give you my social? I mean, I can give you my policy number. It's gonna take me longer.
[AGENT][NEUTRAL] Oh no, the social's fine.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh my social.
[CUSTOMER][NEUTRAL] Is oh actually I have my policy number, so it's 02.
[CUSTOMER][NEUTRAL] 46
[CUSTOMER][NEUTRAL] 5388.
[AGENT][NEUTRAL] Alright, and if you can verify your date of birth and email address.
[CUSTOMER][NEUTRAL] Date of birth is [PII] and I believe the email address I have on file is [PII] [PII].
[AGENT][NEUTRAL] Thank you for that information and what is the date of service for the claim?
[CUSTOMER][NEUTRAL] So I have a few of these bills in front of me, uh, the one date of service says.
[CUSTOMER][NEUTRAL] It was on [PII].
[CUSTOMER][NEUTRAL] So [PII] from.
[AGENT][NEUTRAL] We don't have that on file.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Uh, OK, well, I have the bill in front of me, so like how do I.
[CUSTOMER][NEUTRAL] You know,
[AGENT][NEUTRAL] OK, so we'll just see.
[CUSTOMER][NEUTRAL] It was for an MRI which they had sent me out for.
[AGENT][NEUTRAL] OK, so we'll just need the um you'll just need to contact who's your primary insurance?
[CUSTOMER][NEUTRAL] My primary insurance is uh United Healthcare, and they picked up most of the, the cost. So then I provided them with the gap insurance.
[AGENT][NEUTRAL] OK, so just let me explain.
[CUSTOMER][NEUTRAL] Oh, OK, go ahead, I'm listening.
[AGENT][NEUTRAL] So if you can please contact, yeah, I was asking that question so that I could tell you please contact United Healthcare, ask them for the explanation of benefits for that data service.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And then contact the provider if that billing that you have in your hand doesn't have the diagnosis code.
[AGENT][NEUTRAL] If you can ask them to send you the diagnosis code for that data service and those are the only two pieces of information we'll need to process the claim and pay you directly.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Well, OK, I understand what you're saying right now.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEGATIVE] But I haven't paid these bills, so meaning like uh you're asking me to pay this and then I would get something back from you guys?
[AGENT][NEUTRAL] I'm not asking you to pay it. I'm saying if they're not going, we don't have the claim on file so they did not send it so you can either ask them to send the bill to us or if they don't wanna send the bill to us, I was giving you the information on how you can file yourself to get the money to pay the bill.
[CUSTOMER][NEUTRAL] Or is it something that you know.
[CUSTOMER][NEGATIVE] Is this something that I can do online because I created a portal uh last week, but every time I try to put in my information it's not allowing me to go in.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, now, that is.
[AGENT][NEUTRAL] We have been having um they did uh roll out a new online service center um but they did fix that issue so you should be able to um register a new account and um go in and upload those documents, but those are the only two documents that we'll need if you're going to file yourself.
[CUSTOMER][NEUTRAL] So can I give you the other dates of service because like I said it's more than just the one that I mentioned to you to see if you have that one.
[AGENT][NEUTRAL] OK, what's the other data service?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, we don't have that on file.
[CUSTOMER][NEUTRAL] OK, and then there's another one.
[CUSTOMER][NEUTRAL] For uh
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] That's for the.
[AGENT][NEUTRAL] OK, we have one claim on file from the facility and we paid that. We pay the $606 that they asked for.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It's saying that I still owe 19843.
[AGENT][NEUTRAL] And that's the facility claim?
[AGENT][NEUTRAL] Because your patient responsibility for that.
[CUSTOMER][NEUTRAL] Uh, for the ultra.
[AGENT][NEUTRAL] Is that the facility or the doctor that did it because we only received one claim for that data service and that was the facility.
[AGENT][NEUTRAL] And your patient responsibility for that facility was only $606 and we paid that but we haven't received any other claims from anyone else for that data service.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I mean, I don't, I went to a hospital, like it wasn't the doctor, my GYN referred me out. So then I went to the hospital to go do this ultrasound breast thing and the breast tomosynthesis or whatever and the mammo.
[CUSTOMER][NEUTRAL] It's like a bunch of different things included on this.
[CUSTOMER][NEUTRAL] It says the whole bill was $1,229. The insurance paid.
[CUSTOMER][NEUTRAL] 136 19 adjustments and discounts 89438 but it's still saying that I owe 198 43 so I don't even see the $600 that you're talking about.
[AGENT][NEUTRAL] Because that's the facility claim. When you go to the, whoever performed the procedure has to be paid as well. So that may be the charges for whoever performed the procedure.
[CUSTOMER][NEUTRAL] Of any of that call.
[CUSTOMER][POSITIVE] Great.
[AGENT][NEUTRAL] Your facility claim, normally when you go to the hospital, it's more than one person getting paid. The facility gets their money and the doctors that work in the facility bill out as well, separate from the facility. What I'm saying is we've only gotten the facility claim. So the doctors have not billed for that, and that may be the bill that you're looking at.
[AGENT][NEUTRAL] Because I'm showing that your facility total was $3,574 and your patient responsibility was $606 and we pay that in full.
[CUSTOMER][NEUTRAL] And and like, OK, so in this specific, for this specific claim there wasn't really a doctor.
[CUSTOMER][NEUTRAL] like involved. It was like the ultrasound. It wasn't like, uh, you know, I didn't even see a doctor.
[CUSTOMER][NEUTRAL] Is that something different that you're talking about?
[AGENT][NEUTRAL] OK, if it's for that same data service.
[CUSTOMER][NEUTRAL] It's for 3 2020 25, and it has 123456.
[AGENT][NEUTRAL] OK, well we only have one claim.
[AGENT][NEUTRAL] And normally with the facility claim you get several different bills you get the the providers um.
[AGENT][NEUTRAL] But we only got the facility claim, so you would just need to submit the paperwork for that claim or they can or you can call whoever's billing you and tell them that you have gap and ask them if they're gonna file but.
[AGENT][NEUTRAL] We just need to get the claim to process it we don't have it is what I'm saying.
[CUSTOMER][NEGATIVE] For, OK, so for the first one that I told you from [PII], I have 3 different emails back and forth with these people with copies of this bill with copies of my uh insurance card for the gap, and they still keep sending me this so like it's kind of pointless to reach out to them because I'm getting nowhere with them.
[CUSTOMER][NEUTRAL] Like I have emails dated from back in November of last year.
[AGENT][NEUTRAL] Right, that's what I was saying if they don't.
[AGENT][NEUTRAL] That's why I stated if the provider doesn't want to bill it then you can file it yourself.
[CUSTOMER][NEUTRAL] And I'm telling you that I cannot access my account. I've tried all weekend long. I've just tried right before I made this this call, so I'm calling to try to get it done through a person, meaning like someone like you who's a representative that can assist me with this.
[AGENT][NEUTRAL] But we need documents so if you can't upload them I can give you a fax number where it can be faxed to us if you can't upload it.
[CUSTOMER][NEGATIVE] OK, can you please provide me? Give me one second. I'm gonna grab a pen. Please provide me with that fax number because uh, it is just, it's starting to get very frustrating because I keep going back and forth with all kinds of different companies and nothing's getting done.
[CUSTOMER][NEUTRAL] So where do I fax this to and what do I put on the subject line?
[AGENT][NEUTRAL] OK attention claims department?
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] And the fax number is [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII] 3.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK, um, and for what?
[CUSTOMER][NEUTRAL] Uh, are you ma'am.
[CUSTOMER][NEUTRAL] Uh, just one quick question if I get it online. Are you in the state of [PII]?
[AGENT][NEUTRAL] No, we're located in [PII].
[CUSTOMER][NEUTRAL] [PII]. OK, so let me ask you a question when you're contracted.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] If you take uh a certain insurance you're contracted, I know in the state of [PII].
[CUSTOMER][NEUTRAL] You're only the adjustments that are made.
[CUSTOMER][NEUTRAL] If you send $1000 bill and you, uh, contracted and your insurance company gives you $800 the patient doesn't pay the $200. They don't, they can't balance bill you in the state of [PII] against the law. My ex-wife works for a doctor's office, so.
[AGENT][NEUTRAL] Now this is a question, I'm sorry, this is a question for the major medical. We're the gap insurance so we don't determine any type of uh in-network discount or anything. We only process the claim after it has passed through the major medical and they have assigned patient responsibility. That's why we need the EOB from the primary because that tells us how much we have to pay. So that right there, your question is gonna be directed to United Healthcare.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right, but I'm saying this in the same way in in the state of, uh, [PII] where because these doctors in [PII] tend to, you know, that's why insurances stepped in and say, OK, you can only charge this patient for so much. This is what we're gonna pay you if you accept our insurance, just what you contracted to take anything that other than the copay.
[CUSTOMER][NEUTRAL] And does that, is that the way it works in [PII] because they can bill you whatever they want, right? Um, and that's the whole purpose of being contracted. If they take their insurance, their contracts X amount of dollars. I is that the way it works in [PII]?
[CUSTOMER][NEUTRAL] Or do you have representatives in [PII] we can talk to because I, I think what they're trying to do here, to be honest with you, is
[AGENT][NEUTRAL] What the, that's not our realm though. We, we're supplemental gap insurance. We, so that's the, that's not our.
[CUSTOMER][NEUTRAL] You, I understand what gap mhm.
[AGENT][NEGATIVE] This whole question has nothing to do with us.
[CUSTOMER][NEUTRAL] So you wouldn't know the answer to that question what you said.
[CUSTOMER][NEUTRAL] OK, that's what I'm saying, so you would know the answer that question. So she probably will contact a representative in [PII], like her local representative that handles her primary insurance to find this answer out. I think that's what we're trying, what I'm trying to get to because I think this additional money is money that's being billed to her that she should not have to pay. That's the whole purpose of having a contract.
[CUSTOMER][NEUTRAL] So you, you're right, it's not your situation. I just didn't know if you, if you knew about that.
[AGENT][NEUTRAL] No, because I, I just can't, right, since we're we're not the major medical now if I was a representative for United Healthcare, then I could say yes if she went to an in-network provider and her discounted rate was if the bill was 500 and they were billing 500 and we say hey um.
[AGENT][NEUTRAL] Ms. [PII] went to an in-network provider they're in our network, so you're only charged 250 and then the, the bill price is $250 because you're in network. So now we're gonna take that 250 and oh, Ms. [PII] hasn't met her deductible, so we gotta apply 100 to her deductible and now her responsibility is 150 and then that's the $150 that comes to us the gap and that's what we pay.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right, right, so the patient responsibility should actually be zero. No, I get what you're saying. Yeah, I know, and then actually you do know something about it.
[AGENT][NEUTRAL] OK, so, but I'm not with United Healthcare.
[AGENT][NEUTRAL] I'm, I'm not with, I, I just did, OK. I do know, but because I'm not the major medical, I can't speak on that.
[AGENT][NEUTRAL] That that that's what I'm saying, but I do know how it works.
[CUSTOMER][NEUTRAL] Right, no, I understand, I understand.
[CUSTOMER][POSITIVE] No, no, no, no, no, no, you explained to me exactly what I want to hear.
[AGENT][POSITIVE] I do know how it works.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, no, I, I, that was what I wanted to hear but I know how, I mean, I'm not even sure.
[AGENT][NEGATIVE] I, I just didn't want it to be like, well, the APM told me that y'all was supposed to do this. I, I just didn't want it to go like that.
[CUSTOMER][NEUTRAL] No, no, no, not at all, not, not, no, no, no, not, not at all. I just know, I mean, I, [PII], I, I, I'm never in the insurance business. I've been affiliated to the automobile business with many, many years, and that I know what gap insurance covers typically the whole purpose of having gap insurance is so the patient has no responsibility other than the copay. So I just think that they're trying to get additional money. So we'll, we'll contact your primary care or the doctors because.
[AGENT][NEUTRAL] But I think the thing here, if I can just speak, um, the, the problem here is we haven't received the claim and we can't process a claim that we don't get.
[AGENT][NEGATIVE] Um, and so if you can see from her other claims that we paid, you know, no one has a problem sending us claims and no one has a problem getting payment. Her problem here is we don't have them. They didn't send them and I think that because of the data service it's so far away they probably don't know that we don't have a timely filing.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Exactly.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Rule because normally insurance companies have to submit a claim within a certain amount of time or it'll be denied for timely filing so they're probably thinking, oh this is way back in October they're not gonna accept the claim but we will. So the, the problem, the only problem here is we just need the claim whether she sends it in or whether they send it in we're gonna process it and we're gonna make payment.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] I understand. So we could probably just go by the doctor's office and get copies of it and just and just fax it to you, probably the easiest thing because they're not being cooperative.
[CUSTOMER][NEUTRAL] Well, but these, so could I send in all these bills that they're sending me, uh, you know, like to that fax number that you're saying or I still need the diagnosis code and, and the other.
[AGENT][NEUTRAL] I just wanted
[CUSTOMER][NEUTRAL] Go ahead.
[AGENT][NEUTRAL] I just wanted to be clear, the only two pieces of information we need to pay a claim is a diagnosis code and an explanation of benefits from your primary insurance. Anything else that you send us?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEGATIVE] is futile.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Right, well, we can go by there's the expiration date. We, we can just go by.
[AGENT][NEUTRAL] It's irrelevant. Those are the only two pieces of information we need, the only 2 pieces.
[CUSTOMER][NEUTRAL] Yeah, I know what you're looking for. I, I understand. With diagnosis code you have no way of applying to anything. I understand that. And it explains the benefits. I got that as well. So we just worst case scenario, if this doesn't, you know, we can always go by the doctor's office, uh, you know, and pick up the paperwork and then they can fax it from there whatever we got to do and.
[CUSTOMER][NEGATIVE] Just go from there and I just let them know I won't tell me not getting any more money because that that's just that's wrong, you know, it's just wrong, you know that's what about as a gift you are stay a part of the downfield.
[CUSTOMER][POSITIVE] So a lot of people don't know that. I appreciate your help. Thank you so much. You've been such a big help and I sorry [PII]. Have a great day. Thank you.
[AGENT][NEUTRAL] All right.
[AGENT][POSITIVE] Well, thank you for calling.
[AGENT][POSITIVE] OK you too thank you bye bye.
[CUSTOMER][NEUTRAL] Alright bye bye.