AccountId: 011433970860
ContactId: efd4a1ab-7cb6-48d3-8959-4d53edf6535b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 804090 ms
Total Talk Time (AGENT): 377705 ms
Total Talk Time (CUSTOMER): 259904 ms
Interruptions: 2
Overall Sentiment: AGENT=0.5, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/10/efd4a1ab-7cb6-48d3-8959-4d53edf6535b_20250210T15:55_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII]. I'm calling from Florida Cancer Specialists, and I just wanted to verify eligibility on the patient.
[AGENT][POSITIVE] Yeah, I could check eligibility for you. You said I'm so sorry, you said your name was [PII].
[CUSTOMER][NEUTRAL] [PII] and yours?
[AGENT][NEUTRAL] It's [PII]
[CUSTOMER][NEUTRAL] All right.
[AGENT][POSITIVE] And then can I get a good call back number from you please [PII] just in case we're disconnected.
[CUSTOMER][NEUTRAL] Yes, [PII].
[AGENT][NEUTRAL] OK, thank you and then do you have the policy number?
[CUSTOMER][NEUTRAL] I have 2300701.
[AGENT][POSITIVE] OK, thank you one moment.
[AGENT][NEUTRAL] OK, and what was the name and date of birth for the insured?
[CUSTOMER][NEUTRAL] The what? I'm sorry?
[AGENT][NEUTRAL] The name and date of birth for the member?
[CUSTOMER][NEUTRAL] It is [PII], [PII].
[AGENT][NEUTRAL] Perfect, thank you for verifying that. Uh, so this policy is active. Effective date was [PII], and this is a secondary medical policy, so it is designed to help with co-pay, deductible and co-insurance after major medical pays.
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] OK, because, and the reason I asked is because I have some claims that uh Aetna is primary and paid and it looks like they billed the balance to you guys in October.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And it's still sitting here I can give you a date.
[AGENT][NEUTRAL] Let me take a look.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] Uh, the date of service?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] That would be great, yeah, go ahead.
[CUSTOMER][NEUTRAL] OK, [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Bear with me just a moment, and this was for [PII], correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, looks like we got a few claims for that date of service. Um, do you happen to have that bill amount?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh, $339.
[AGENT][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] Was that a Florida cancer specialist?
[CUSTOMER][POSITIVE] Yes, yes it is.
[AGENT][NEUTRAL] OK, let's take a look here. Alright, so we did receive this claim uh looks like we were unable to pay a benefit as their outpatient benefit for the calendar year had been met.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Oh, so calendar year meant.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][MIXED] OK, but the other ones did pay.
[AGENT][NEUTRAL] Um, what were those dates of service?
[CUSTOMER][NEUTRAL] No, for [PII].
[CUSTOMER][NEGATIVE] Some pain.
[AGENT][NEUTRAL] Let's take a look.
[CUSTOMER][NEUTRAL] Uh, but I, I also.
[AGENT][NEUTRAL] Yes, I have a couple that I'm showing.
[CUSTOMER][NEUTRAL] Well
[AGENT][POSITIVE] Good. Let's see.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah, she's got quite a few. Uh what was another one that was it, uh, build them out?
[CUSTOMER][NEGATIVE] I paid or not paid.
[AGENT][NEUTRAL] Um, either whatever you'd like for me to check.
[CUSTOMER][NEUTRAL] OK, uh, go ahead and check [PII].
[AGENT][NEUTRAL] Was that the, I'm sorry, was that the amount or was that the date?
[CUSTOMER][NEUTRAL] The date.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] What was the bill amount for this one?
[CUSTOMER][NEUTRAL] $1,029.
[AGENT][NEUTRAL] OK, let's see.
[AGENT][NEGATIVE] OK, so for this one we received this one as well. Um, this one wasn't, we weren't, uh, excuse me, unable to pay a benefit as the services are not covered when performed in a doctor's office or clinic.
[CUSTOMER][NEUTRAL] Oh,
[CUSTOMER][NEUTRAL] So not covered, so what is, what is the plan cover?
[AGENT][NEUTRAL] Let's see. So this plan, again, they're all a bit different. It is secondary medical, um,
[AGENT][NEUTRAL] I'd say more, you know, supplemental in that sense it does have its own policy as to what is and is not covered. um, it's going to be more for outpatient facilities, uh, surgeries, things like that. They also have an inpatient benefit, not so much office visits or treatment received in office.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So surgeries and what else did you say?
[AGENT][NEUTRAL] They have inpatient benefits as well, um, yeah.
[CUSTOMER][NEUTRAL] Inpatient.
[CUSTOMER][NEUTRAL] OK, that makes sense. I get it. OK, so anything I have that's older that we billed to you and is not paid, that's because it was done in the doctor's office.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] We can verify if you'd like, but most likely. Do you want me to check for you?
[CUSTOMER][NEUTRAL] No, because it's, it's for this, no, because it's for the same amount, so.
[AGENT][NEUTRAL] Oh, I see. OK, OK, yeah, that's a safe guess.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, but my question to you is, should we bill you anyway?
[AGENT][NEUTRAL] Uh-huh.
[AGENT][POSITIVE] You absolutely can.
[CUSTOMER][NEUTRAL] To get the denial or you can, we can.
[AGENT][POSITIVE] You absolutely can. That's completely up to you, yes.
[CUSTOMER][POSITIVE] OK, because I have a lot of claims here that have $60 and they're from the doctor's office, so now I know that I can build a patient.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] So and then just so that you are aware um all of these plans are very different so if you have other patients coming in with this kind of coverage it's possible that theirs could cover office visits or treatment received in office so just so that you're aware.
[CUSTOMER][NEUTRAL] OK, um.
[CUSTOMER][NEUTRAL] Alright, um
[CUSTOMER][NEUTRAL] I have one other one here I just wanna verify.
[AGENT][NEUTRAL] Mhm. Sure.
[CUSTOMER][NEUTRAL] Uh, um, well, this one's a little different but.
[CUSTOMER][NEUTRAL] Oh, I think this needs to go back to Aetna. One second. I'm totally confused. I'm just helping out Aetna, but something is weird. OK, um, OK, let's look at this one. This one, the date was [PII].
[AGENT][NEUTRAL] Sure.
[AGENT][POSITIVE] You're OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] The total bill there was 4,686.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] 4686, OK.
[CUSTOMER][NEUTRAL] And we received, I guess from you $500. I don't know if that's correct.
[AGENT][NEUTRAL] OK, bear with me just a moment.
[CUSTOMER][NEGATIVE] I think this is a Aetna problem.
[CUSTOMER][POSITIVE] No, because you paid the copay, yeah, no, you're good.
[AGENT][NEUTRAL] Let's see. Florida cancer specialist, yes, I did, I think. No, that's not it. That's a different one.
[CUSTOMER][NEUTRAL] But they had a deductible. They had a deductible.
[AGENT][NEUTRAL] I
[AGENT][NEUTRAL] Mhm. And that's what this plan is supposed to help with assuming, of course, that it would be covered procedure under this policy. I think I found it.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Because it paid the $500 for the copay, but not the deductible.
[AGENT][NEUTRAL] OK, so for this one, just to verify it looks like, uh, the two procedure codes uh 78815 and 89552, is that correct?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Yeah, that's correct.
[AGENT][NEUTRAL] OK, so this is going to be a separate benefit. This one is for uh specifically for cancer outpatient treatment. So that's why we were able to pay that benefit of $500.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][MIXED] OK, but you don't pay the deductible?
[AGENT][NEUTRAL] I'm not showing that that's what we received um I'm showing that for the procedure code 78815 that was $450 and then the uh 9552 was $50.
[CUSTOMER][NEUTRAL] Right, but it's showing there under the patient responsibility column.
[CUSTOMER][NEUTRAL] Uh, of $1550 deductible if you can see the you know explanation.
[AGENT][NEUTRAL] Let me pull up the, I'm gonna pull up the EOB yeah because we don't usually say what is patient responsibility that's usually just up to the provider so let me take a look at what we've got give me just a moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, because it was all on the same EOB.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, let's see.
[CUSTOMER][NEGATIVE] I see that that's too much if you're right that's.
[AGENT][NEUTRAL] Bear with me. I'm sorry. It's thinking about it.
[CUSTOMER][NEUTRAL] No, you're fine you're fine.
[AGENT][NEUTRAL] OK, so I did find our EOB that does show that total bill charges as the 4,686, um, but I'm not seeing anything as far as patient responsibility, it simply shows those items for $450.50 dollars and typically that's when we received that information that's what we can pay, so I can send you this EOB if you'd like.
[CUSTOMER][NEUTRAL] No, do I need to send you my EOB?
[AGENT][NEUTRAL] No, unless you think there's something missing.
[CUSTOMER][NEUTRAL] Yeah, because, uh, and now that I'm seeing not only copay, but like I said, the deductible and co-insurance.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me take a quick look here.
[AGENT][NEUTRAL] See if I can see.
[CUSTOMER][NEUTRAL] I mean we only have one ELB.
[AGENT][NEUTRAL] Sure, I can see if.
[AGENT][NEUTRAL] Because that was the EOB that we sent to you so let me see if I am able to see and not a claim specialist, um, I kind of just see like surface level, but let me see if I can see um what was sent to us, so give me just a moment.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK, I think I see.
[AGENT][NEUTRAL] What y'all sent OK so for this again, um, I'm, I'm just kind of surface level so if you would like I can put you on a brief hold and reach out to our claims specialist just so they could take a look and make sure that this is accurate.
[CUSTOMER][POSITIVE] OK, I appreciate it.
[AGENT][NEUTRAL] So from what you're showing how much is the you're showing that we have, we didn't pay any of the deductible is that right?
[CUSTOMER][NEUTRAL] And the co-insurance.
[AGENT][NEUTRAL] OK, and how much was that? Do you know? Mhm.
[CUSTOMER][NEUTRAL] 71. OK, uh, the deductible was $1550 and the co-insurance was $71.
[AGENT][NEUTRAL] 71. OK, alrighty, um, bear with me just a moment. I'm just gonna put you on a brief hold and reach out to them, uh, again so they could take a look. I'll get right back with you, OK?
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] Thank you one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Ferring
[CUSTOMER][NEUTRAL] This is [PII].
[AGENT][NEUTRAL] Hi Ay, this is [PII] over on the care team. How are you?
[CUSTOMER][POSITIVE] I'm good. How are you?
[AGENT][NEUTRAL] Doing all right thank you. I have a provider on the line calling regarding a uh medlink claim um we did pay the full benefit. She's stating that uh she believes that there were items missing, um, that we should have been able to pay and wants to take a closer look at that.
[CUSTOMER][NEUTRAL] OK. And her name?
[AGENT][NEUTRAL] [PII], so [PII]
[CUSTOMER][NEUTRAL] And her callback number?
[AGENT][NEUTRAL] It is [PII].
[CUSTOMER][NEUTRAL] OK. And the policy number?
[AGENT][NEUTRAL] That is 2300701.
[AGENT][NEUTRAL] And it is for uh part two.
[AGENT][NEUTRAL] And I've got the claim number that we're looking at too.
[CUSTOMER][NEUTRAL] OK, what's the claim number?
[AGENT][NEUTRAL] It is 3451167.
[CUSTOMER][NEUTRAL] 400
[CUSTOMER][NEUTRAL] OK, I have it pulled up. You can send her over.
[AGENT][POSITIVE] All right, appreciate it. Thank you.
[CUSTOMER][POSITIVE] Mhm. No problem.