AccountId: 011433970860
ContactId: ef28ed77-3926-401a-b635-5e64b25f205d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 647030 ms
Total Talk Time (AGENT): 327526 ms
Total Talk Time (CUSTOMER): 265203 ms
Interruptions: 8
Overall Sentiment: AGENT=1, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/25/ef28ed77-3926-401a-b635-5e64b25f205d_20250425T20:34_UTC.wav
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[AGENT][NEUTRAL] Good afternoon, thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yeah, hi. Uh, I'm calling about uh a claim that I, um,
[CUSTOMER][NEUTRAL] Submitted and uploaded documents for recently?
[CUSTOMER][NEGATIVE] And I haven't received any contact from anyone regarding it. It's been over 3 weeks already, and I was calling in to see.
[AGENT][NEUTRAL] OK, so.
[CUSTOMER][NEUTRAL] And I'm even on the on the website I'm logged into my account and.
[CUSTOMER][NEUTRAL] I don't know why, but I don't see any information on it here.
[AGENT][NEUTRAL] OK, so you are the insured and you uploaded a claim into your portal, but you're not able to see that in the system, is that correct? And you're wanting to check on that?
[CUSTOMER][NEUTRAL] Uh, yeah, I'm not, I'm not seeing it here, um.
[AGENT][NEUTRAL] OK, yes, sir. Well, I can try and help you with this. So first off, uh-huh.
[CUSTOMER][NEUTRAL] Well, actually I, actually, you know what, I think, take, I take that back. I think I do see it here.
[AGENT][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] Um, but there's, there's no more, there's no information on it, so I'd like to see what's going on.
[AGENT][NEUTRAL] Yes.
[AGENT][POSITIVE] OK, yes sir. Well, I'll be happy to take a look at that for you. So who am I speaking with please?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, yeah, my name's uh [PII].
[AGENT][NEUTRAL] OK. And Mr.
[CUSTOMER][NEUTRAL] And I can give you my policy number if you need.
[AGENT][NEUTRAL] OK, I'll get that from you in just a moment. What is a good callback number for you first off, Mr. [PII]?
[CUSTOMER][NEUTRAL] Yeah, [PII].
[AGENT][NEUTRAL] Thank you. And what is your policy number now, please?
[CUSTOMER][NEUTRAL] 1,666,110.
[AGENT][POSITIVE] OK, thank you one moment please.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And the claim is for you, is that correct, Mr. [PII]?
[CUSTOMER][NEUTRAL] Uh, it's for my wife, [PII].
[AGENT][NEUTRAL] OK. OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So first off, I will need to verify uh several pieces of information with you for security and then also any information that is provided would be a verification of benefits and not a guarantee of payment. So if you could first please verify your name, I'm sorry, your date of birth and then your wife's name and date of birth.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm. Yeah, my name is [PII] and uh my date of birth is [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, my wife's [PII] and her date of birth is [PII].
[AGENT][NEUTRAL] Thank you and the home mailing address, please?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And then your phone number that we have on file for you, Mr. [PII] is the same as the one that you provided for me, so that is your best contact number, is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, thank you and the last piece of information to verify will be your email?
[AGENT][NEUTRAL] And then this does appear to be your work email that is on file.
[CUSTOMER][NEUTRAL] Yeah, it's the same one. It's [PII].
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And what is the date of service that you're calling about?
[AGENT][NEUTRAL] That you submitted the claim for for her.
[CUSTOMER][NEUTRAL] Um, the, the date of service.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I guess when the, when the surgery was done.
[CUSTOMER][NEUTRAL] I, I believe it was.
[CUSTOMER][NEUTRAL] Uh, hold on a second, let me.
[CUSTOMER][NEUTRAL] [PII] of last year.
[AGENT][NEUTRAL] OK. All right. So give me just a moment to look at a couple of things, please.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so on the claim that you submitted, Mr. [PII] on the [PII], well, we received it on [PII] and it was processed on [PII]. So it shows that for that service date, the claim you submitted, it was denied.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And the remark on the explanation of benefits states the policy benefits for the listed dates of service have been paid directly to the provider of service. We have previously received a claim for her.
[AGENT][NEUTRAL] For that same uh billed amount and date of service from the provider directly we received that claim from them in January of this year.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And we process that um on claim number and you should be able to see this claim number in your portal but it's.
[AGENT][NEUTRAL] 355.
[AGENT][NEUTRAL] 8138.
[CUSTOMER][NEUTRAL] Yeah, I see that here. Actually, I do see that.
[AGENT][POSITIVE] And we paid a $400 benefit to Miami Surgical Center.
[CUSTOMER][NEUTRAL] So they were paid by us the day of the surgery.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, and then you guys paid them.
[AGENT][NEUTRAL] Yes, because
[CUSTOMER][NEGATIVE] Well, that sounds like fraud to me by them.
[AGENT][NEUTRAL] Well they filed, yeah they filed their claim with us for that data service in January so you what you would need to do is to reach out um to them.
[CUSTOMER][NEUTRAL] Yup.
[AGENT][NEUTRAL] To their billing division, to their billing department?
[AGENT][NEUTRAL] Regarding this.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Because we don't determine, we can't tell them how to bill whether it's just, you know, charge up front because we can't guarantee payment of benefits whenever someone calls just like I explained to you, you know, we can't guarantee the payment so.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] Well, what I don't understand.
[CUSTOMER][NEGATIVE] Yeah, what, what I don't understand is.
[CUSTOMER][NEUTRAL] It's the er OK, so.
[CUSTOMER][NEUTRAL] They obligated us to, so typically when we go have something done for the most part in most places, we say we have our, we give them our insurance card which is Florida Blue, and then we say we have a gap insurance with APL and they will cover up to $500 of the procedure or whatever it is, and they, the, the, the doctor's office or or the or the facility takes care of that. This group um.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] [PII] um
[AGENT][NEUTRAL] Miami surgical.
[CUSTOMER][NEUTRAL] Said no we don't do that you have to pay us now, OK?
[AGENT][NEUTRAL] So, mhm.
[CUSTOMER][NEGATIVE] So I don't understand how they're able to bill you guys for this and and file this claim when they obligated us to pay them and not do how every other place does.
[CUSTOMER][NEUTRAL] And then they get paid on this 3 months later, you know, um, or 4 months later, whatever it is, um.
[AGENT][NEUTRAL] Yes sir because we process the claim.
[CUSTOMER][NEUTRAL] And so they charged us and so they got paid twice for that essentially.
[AGENT][NEUTRAL] We, yes, we issue and based on what you're saying, yes we did issue payment to them back in January.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The claim that we processed for them, which again you should be able to see this in your portal was on [PII] or.
[CUSTOMER][NEUTRAL] Yeah, I see it here.
[CUSTOMER][NEUTRAL] I see it, [PII]. I see it.
[CUSTOMER][NEUTRAL] I see [PII] date received and then it says [PII] date completed yeah.
[AGENT][NEUTRAL] Yes, uh-huh, and then we processed it on the [PII].
[AGENT][NEUTRAL] Correct. And the check number, let's see.
[AGENT][NEUTRAL] The check that we issued, yes, it, it shows that it cleared [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] The payment that we issued to them.
[CUSTOMER][NEUTRAL] OK, alright, so I guess what I need to do is.
[CUSTOMER][NEUTRAL] Uh, I need some sort of document from you guys stating that you paid them though. Uh, is that, can I get that on the site?
[AGENT][NEUTRAL] That EOB
[CUSTOMER][NEUTRAL] Cause I'm gonna have to
[AGENT][NEUTRAL] That EOB should um reflect that payment was issued to them.
[CUSTOMER][NEUTRAL] OK. OK.
[AGENT][NEUTRAL] You should be able to see that information.
[CUSTOMER][NEUTRAL] And I and I can download that from the website.
[AGENT][POSITIVE] Absolutely, yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] OK, um, well, this is, this is, this is a, this is, uh, actually it's upsetting. It really is because they made us pay up front.
[AGENT][NEUTRAL] Um.
[AGENT][POSITIVE] I'm so sorry.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] And, and then I find this out. I mean and and it took me a while to do this because I just hadn't had the time to do it and my wife's like, when are you gonna file this? and I finally did it, um.
[AGENT][NEUTRAL] Sure, no, I, I understand. I've been in a similar situation. Um, as a matter of fact, just, just not too terribly long ago this past year where, um, I had to pay and then
[CUSTOMER][NEUTRAL] And um.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] Insurance still pay, it was overpayment and then I had to get my overpayment back from the provider. So I do understand the frustration that you're feeling at the moment. I really do. Yes, I do. Yes, sir. I certainly do.
[CUSTOMER][NEUTRAL] Yeah, you're in a similar situation, yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Well, you know what bugged me about this place is um that no other place has ever done that to us. They're like, yeah, just give us your, your insurance information and we take care of it. These guys are like, no, you have to pay now.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, sir, and you know.
[CUSTOMER][NEUTRAL] I'm like, well, I'm giving you my APL card, you.
[AGENT][NEUTRAL] And unfortunately, a lot of providers are moving that direction, and this again is my personal own personal experience. They want to be paid up, yes, they want to be paid upfront to ensure that they are paid in case your insurance doesn't cover it.
[CUSTOMER][NEUTRAL] You know, but I mean there's nothing, yeah.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] They're all a lot of them are doing that, huh?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][MIXED] Yes, unfortunately, but yes. Mhm.
[CUSTOMER][NEUTRAL] Yeah, yeah, I see what you mean.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] All right, well thank you for your help. Thanks for helping, uh, get this clarified for me. I appreciate it. All right.
[AGENT][POSITIVE] Well, you're, um, most certainly, yes, but if you have any other questions, um, you can call us back and we'll be more than happy to assist you.
[CUSTOMER][POSITIVE] Sure thing. Sure thing. Thank you so much. You've been very helpful. All right, take care.
[AGENT][POSITIVE] OK. All right. Well, well, you're very welcome, Mr. [PII]. Yes, sir, and thank you for calling APL. I hope you and your wife have a very nice weekend.
[CUSTOMER][POSITIVE] Thanks a lot you have a nice evening too bye bye.
[AGENT][POSITIVE] Mhm. Thank you, bye bye.