AccountId: 011433970860
ContactId: f6bb72db-eb10-4e54-982f-b6bee94f7b19
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 958700 ms
Total Talk Time (AGENT): 357253 ms
Total Talk Time (CUSTOMER): 286872 ms
Interruptions: 1
Overall Sentiment: AGENT=0.1, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/19/f6bb72db-eb10-4e54-982f-b6bee94f7b19_20250219T15:02_UTC.wav
--------------------------------------------
[AGENT][POSITIVE] Good morning. Thanks for calling Aels [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yes ma'am, I was wondering if you could look over a couple of claims with me.
[AGENT][POSITIVE] I can help you with that. Can I get a callback number in case we get disconnected?
[CUSTOMER][POSITIVE] Yes ma'am, and I'm getting a call that's important. I will be right back. I'm so sorry. I'll be right back. Thank you.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Hello.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Sorry about that. My niece is trying to call me about something, but I guess it got hung up. It's OK. Um, I'm sorry, my name is [PII] and my birthday is [PII]. Um I don't have my policy number pulled up, but I can pull it up.
[AGENT][NEUTRAL] Um, let me start by getting a callback number in case we get disconnected.
[CUSTOMER][NEUTRAL] One second.
[CUSTOMER][NEUTRAL] Oh yes ma'am. [PII].
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, give me 1 2nd.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] I'm sorry, can you verify your date of birth again, please?
[CUSTOMER][NEUTRAL] Yes, [PII].
[AGENT][NEUTRAL] Your address?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And lastly, your email address.
[CUSTOMER][NEUTRAL] Um, [PII].
[AGENT][NEUTRAL] OK Miss. Now, thank you for that. You said you wanted to go over a claim?
[CUSTOMER][NEUTRAL] Yeah, the most recent claim that showed to be processed or whatever. I had a question on it. My immunotherapy was on there, but I, I thought I was paid for when I had immunotherapy. And I didn't see any, like, it's the date of service would be [PII]. That's what I'm looking for.
[AGENT][NEUTRAL] Give me 1 2nd.
[CUSTOMER][NEUTRAL] Maybe I'm just misunderstanding how it works.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] I'm just looking at this, give me just a few minutes.
[CUSTOMER][NEUTRAL] No problem. When I go down, I noticed that the 11:[PII] isn't even mentioned on here as the data service.
[AGENT][NEUTRAL] So it is mentioned on here as a data service, um, there is.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] The 11:18 is?
[AGENT][NEGATIVE] Yes, ma'am. There's a, a denial on here, um.
[CUSTOMER][NEUTRAL] Oh, or what?
[AGENT][NEUTRAL] Give me 1 2nd.
[AGENT][NEUTRAL] I'm just trying to look to see to make sure this is the immunotherapy drug, so give me one second.
[AGENT][NEUTRAL] Right
[CUSTOMER][NEUTRAL] I've sent in every claim I know to send. I mean, I've sent the.
[AGENT][NEUTRAL] OK, so
[CUSTOMER][NEUTRAL] EOB, they said that wasn't enough, uh-huh.
[AGENT][NEUTRAL] So, let me pull up the actual claim you well the you will be that was sent in and I can just um.
[CUSTOMER][NEUTRAL] No, no, the, well, before you do that though, the ELB wasn't enough. I had to resend and I sent an actual thing from the insurance company. Oh.
[AGENT][NEUTRAL] Yes, ma'am. I see that, like I'm saying, it was processed yesterday, but this was, this most recent claim was the one that was processed yesterday, so I'm pulling up that one cause that's where this denial came from. So that's why I'm pulling up to see.
[CUSTOMER][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] Uh,
[AGENT][NEUTRAL] Uh.
[AGENT][NEUTRAL] now.
[AGENT][NEGATIVE] As it's taking a few minutes because my system is running slow so.
[CUSTOMER][NEUTRAL] Sure, I understand.
[CUSTOMER][NEUTRAL] So when I'm looking at my claims where it says data service, should it not say [PII] though, or it says [PII].
[AGENT][NEUTRAL] So, are you looking at this online?
[CUSTOMER][NEUTRAL] Let me make sure I'm reading this right.
[CUSTOMER][NEUTRAL] Yes ma'am, I am. I'm looking at my, on my side, yeah, on the APL.
[AGENT][NEUTRAL] So if you, if you select the claim, there should be an EOB attached to it. Um, if not, like I said, this was just processed, um, let me see so.
[AGENT][NEGATIVE] Yes, this was this process yesterday, so that could be the reason why you can't see the EOB, um, because it, um, but like I said for that data service, it was denied because the EOB, it shows there's no benefits provided as a provider of service like your primer, they did not accept any payments for the services.
[AGENT][NEUTRAL] So that's the reason why I wasn't paid, but it is on that claim.
[CUSTOMER][NEUTRAL] It.
[CUSTOMER][NEGATIVE] OK, what do you mean didn't accept any payments for the services you mean like I didn't pay out of my pocket for it, is that what you're saying?
[AGENT][NEUTRAL] No, it has to do with your primary insurance that you will be.
[AGENT][NEUTRAL] So on the EOB it's not showing.
[CUSTOMER][NEUTRAL] OK, but.
[CUSTOMER][NEUTRAL] Yes ma'am, I understand y'all already told me that last week and that's why we went and sent you the new thing from Blue Cross Blue Shield showing it's not the EOB it's a claims history report and it has everything procedure codes. Did y'all not receive that one?
[AGENT][NEUTRAL] Which date are you referring to? I mean, that you sent, sent in because I, I mean, I know I spoke with you about maybe about a week or two ago and I went over what we had and basically what we had was not showing, so whatever was processed yesterday was um
[CUSTOMER][NEUTRAL] Hi.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK, well, since then I have sent you new information and I even got confirmation that it's sent. We did it through, we did it directly to the site. My sister sent it to, uh, to y'all. Uh, let me take a look at what day it was, uh, today is [PII], Wednesday. Let's look here.
[AGENT][NEUTRAL] The [PII].
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Yeah, we've already sent it and I got confirmation that it was sent and it even it even has the whole showing you the procedure code and everything. This is not the EOB this is something different. So are you, are you not showing to have received anything else?
[AGENT][NEUTRAL] So what we processed yesterday, we received, and what we received yesterday, let me go back to that document.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right I'm going back to where my sister and I sent it.
[CUSTOMER][POSITIVE] Yeah, and it was an act of Congress. I had to go through the insurance company to get a, then I called the actual doctor's office and the doctor's office actually got me what I needed.
[CUSTOMER][NEUTRAL] And that had all the procedure codes and all of that on it. And that's what we sent you, not this was after the EOB.
[CUSTOMER][NEUTRAL] And that's what y'all need, right?
[AGENT][NEUTRAL] Yes, we need to be, so I'm looking at the, the last documents that we received on [PII]. So one of the documents I received, it was 4 pages and it shows hospital services from um the acute care clinic and it has the procedure code for that immunotherapy. That's one of the documents. Let me pull up the other cause it looks like there are 2 more. One second.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] But was that was that one denied?
[AGENT][NEUTRAL] Give me one second, ma'am. I'm just pulling up the other documents to see what the other ones are, and I can um compare it.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Blue Cross explained to me that their EOBs do not have all the information anymore that is needed, that you have to do a claims history report or go to the doctor, which is crazy to me, but that's what they told me.
[AGENT][NEUTRAL] Uh, let's see where did you go? OK, so let's.
[AGENT][NEUTRAL] OK. So, we received the EOB that was sent in by you and your sister, so.
[AGENT][NEUTRAL] The charges for the immunotherapy are the $43,769.21. When we're looking at the you'll be from
[AGENT][NEUTRAL] Your insurance company, it's showing, if you look at the EOB as well, and you can see what I'm referring to, so it's showing that the provider billed $443,769.21. If you look in the next column, it says member discount.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] So that is showing that your primary, there's nothing that was due for you to pay. So that's the reason why we can't pay because on this EOB it's not showing anything that you were billed. So that's why there's nothing paid for that.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh, that that I was personally billed.
[AGENT][NEUTRAL] That is correct. So you would have to contact your insurance to find out why.
[AGENT][NEUTRAL] There that you are not being charged anything because it's showing like there's nothing, there's nothing to pay. So we can't pay anything if there's nothing um that you're responsible for.
[CUSTOMER][NEUTRAL] OK, so if my out of pocket were met, that would be the reason though, right?
[AGENT][NEUTRAL] I can't say that. You would have to contact your insurance and they would verify that with you. We are only going by what's on this EOB.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Because my out of pocket was met when they did that procedure.
[CUSTOMER][NEUTRAL] That's the only thing I can think of.
[AGENT][NEUTRAL] I mean, that could be the case of like say, you would have to contact your insurance to verify that, but like I said, based on this, it's not showing that you had to pay anything. It's showing that it just says member discount.
[CUSTOMER][NEUTRAL] I mean, I don't
[CUSTOMER][NEUTRAL] OK, I thought I was paid so much each year for immunotherapy, and I thought it started over [PII].
[AGENT][NEUTRAL] So the way, I mean, that is correct, but however, your policy, it goes by actual charges and actual charges we go by what's based, what's on the EOB and so like I said, since the EOB does not show anything that you had to pay, then we can't pay anything because that's how that works.
[CUSTOMER][NEUTRAL] OK, I'm so confused. I don't understand, but I'm trying to understand when I had it before.
[AGENT][NEUTRAL] So when it comes to um immunotherapy, chemotherapy, radiation, your policy is an actual charge policy. Actual charges means we go by um member responsibility that is on the EUB. So since you had no responsibility, we can't pay anything. So under member responsibility, it's, it's zero.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] OK. I was trying to understand from when I first had it, the first year, my out of pocket was met as well, and I still got paid for immunotherapy. So I'm still confused on
[AGENT][NEUTRAL] Well, the only time, like I said, the only time we pay is like if there's something due, and I can pull up a previous one, but like I said, that is how um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] It works on this, um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 84.
[CUSTOMER][NEUTRAL] All right, is there anything else I need to send in then? Have y'all pretty much, and I haven't done my hotel stay for a while back yet. I haven't done my gas things, uh, you know, my transportation yet, but I don't know of anything else that I should be sending in then.
[AGENT][NEUTRAL] Let me see what else was um.
[AGENT][NEUTRAL] With on that claim, if there's anything else that needs to be sent in, give me one second.
[AGENT][NEUTRAL] The only thing that needs to be sent as for your transportation for [PII], um, you would just need to send in, um, the facility address.
[AGENT][NEUTRAL] But we paid the physical therapy for.
[CUSTOMER][NEUTRAL] OK, and the transportation.
[CUSTOMER][NEUTRAL] Oh, I'm sorry, go ahead.
[AGENT][NEUTRAL] But we did pay for the physical therapy dates on this claim. So you should be receiving that.
[CUSTOMER][NEUTRAL] OK, will that come into the bank account?
[AGENT][NEUTRAL] Let me see if if direct deposit is set up, um.
[CUSTOMER][NEUTRAL] It's just how I had it.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] OK. All right. Well, thank you for your help and I'll, I have a bunch of old transportation from chemotherapy that hasn't been used yet and stuff like that. I just don't know exactly what to send you for that.
[AGENT][NEUTRAL] So what you would, you would just send, um, you can send in, um you can just write it on a piece of paper like the dates and the addresses for those treatments and you can send it in. And if we see that there's chemo charges or any radiation charges or anything that falls under that, then we'll pay the transportation as long as it's more than 50 miles one way.
[CUSTOMER][NEUTRAL] An address of some sort?
[CUSTOMER][POSITIVE] Yes, ma'am. OK, well, thank you. You have a good day.
[AGENT][POSITIVE] Useful, Ms. [PII]. Was there anything else that I can help you with today?
[CUSTOMER][POSITIVE] No, ma'am. Thank you.