AccountId: 011433970860
ContactId: f728add7-2477-49ba-be87-4a03fab4f694
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 766770 ms
Total Talk Time (AGENT): 394008 ms
Total Talk Time (CUSTOMER): 407392 ms
Interruptions: 15
Overall Sentiment: AGENT=1.1, CUSTOMER=0.9
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/05/f728add7-2477-49ba-be87-4a03fab4f694_20250205T22:10_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][POSITIVE] Hi, good afternoon, how are you?
[AGENT][POSITIVE] I'm doing well how are you?
[CUSTOMER][NEUTRAL] I'm doing well. Um, I'm calling because, um, I had a surgery in January last year and just received a letter from the anesthesia provider, um, stating that, um, they sent the bill to APL as my, my, my, my, my secondary insurance and APL denied the claim and said to submit it to the primary, which is Aetna.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] I contacted them today, um, the anesthesia provider, and they stated that the reason why APL, uh, denied the claim according to a letter that they had from APL is because, um.
[CUSTOMER][NEUTRAL] A check had already been sent out um for this.
[AGENT][NEUTRAL] Oh,
[CUSTOMER][NEUTRAL] We did receive a check in November, but the check for it was the exact amount I believe it was like $3700. I have the exact number was for the hospital bill. So the surgery, you know, the it was in the hospital, so the received the bill from the hospital and not from exactly not so the amount.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right. But not for the anesthesia.
[AGENT][NEUTRAL] Gotcha. Oh my goodness. OK.
[CUSTOMER][NEUTRAL] Yeah, so the amount in the check was exactly the same amount from the hospital bill, and it was $3,786 and as soon as we got the check we sent it to the hospital and paid that bill, but we still have a $1500 bill remaining uh from the anesthesia. We have not received the checks for that, so I wanted to see if you could help me.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Got you. OK. Goodness, I'm sorry. That just sounds like a lot of back and forth confusion. So all right. Yes, OK, well, first, let's verify that we did receive that claim uh for the anesthesia and we can go from there. Um, what was your name? I'm sorry.
[CUSTOMER][POSITIVE] A lot of back and forth, yeah, exactly.
[CUSTOMER][POSITIVE] Awesome.
[CUSTOMER][NEUTRAL] Uh, I'm sorry, I didn't say it before. [PII].
[CUSTOMER][NEUTRAL] [PII], and I have if you need the um the group ID or the pay ID um any of that information I could.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Do you have the policy number by chance? Are you looking at your, uh, ID card?
[CUSTOMER][NEUTRAL] Yeah, I'm looking at the card. Yes, is it the, OK, yeah, the in hospital.
[AGENT][NEUTRAL] OK, it should be at the bottom, yes, either one of those.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK, yeah, so the inhospital one is 01.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 49205 ML 7
[CUSTOMER][NEUTRAL] And the other one is the same but ending in 8.
[AGENT][NEUTRAL] OK, I'm sorry I don't think I heard all of those uh digits. Could you repeat that? I'm so sorry.
[CUSTOMER][POSITIVE] OK, yeah, yeah, no, you're good. It's 01849.
[CUSTOMER][NEUTRAL] 205.
[CUSTOMER][NEUTRAL] M as in Mary, L as in Larry, 7.
[AGENT][NEUTRAL] OK thank you and then um before we go any further, uh can I get a good call back number from you in case we're disconnected please?
[CUSTOMER][NEUTRAL] Yes, [PII].
[AGENT][POSITIVE] OK thank you and I apologize, could you pronounce your name for me again just so I make sure I pronounce it right?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII], OK, thank you. OK, I'm just gonna verify some of your information really quick. Uh, can I get your date of birth, please?
[CUSTOMER][NEUTRAL] Yes, [PII].
[AGENT][NEUTRAL] Thank you and then can I get your mailing address?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK perfect thank you for verifying that OK and then just to confirm um this claim was for you correct?
[CUSTOMER][NEUTRAL] No
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] And the date of service is um [PII].
[AGENT][POSITIVE] Do you, oh yes, please. Thank you.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] [PII], so it's just a year ago.
[AGENT][NEUTRAL] OK, [PII], alright.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And to the, the anesthesia provider that sent the letter is called Envision P Physician Services.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Vision
[CUSTOMER][NEUTRAL] Anesthesia
[AGENT][NEUTRAL] Physician services.
[CUSTOMER][NEUTRAL] Efficient physician services.
[AGENT][POSITIVE] OK, thank you so much for all of that information that sure makes it a lot easier. OK, bear with me just a moment let me try to.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][POSITIVE] Yeah, thank you.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Locate this.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK and you said they were billing you for um I'm sorry, go ahead.
[CUSTOMER][NEUTRAL] they also say that they.
[CUSTOMER][NEUTRAL] No, they, they, oh, they didn't bill me. They sent me the letters saying we sent the claim to APL APL said that um we had to send it to the premier insurance which is Aetna, so just give us a call so you could provide that information. So when I called them they said no, we sent it to Aetna first.
[CUSTOMER][NEUTRAL] Um, and, uh, paid some of it, uh, didn't pay $1500 so we then sent the remaining amount that I think and I only paid like, like $200238 so we sent the remaining.
[AGENT][NEUTRAL] Yes, yes.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Training amount to um APL and apparently they received an uh an EOB from APL saying that that was a duplicate that that was a duplicate um um claim or something like that.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] So here's where the confusion is. Yes, here's where the confusion is, um, and again I I'm so sorry that you're in the literally in the middle, um, here you're in all sides, um, but for this what we needed was the explanation of benefits from your primary.
[AGENT][NEUTRAL] Insurance so from Aetna essentially showing us what they paid it's not necessarily that it had to go to them, um, so wherever you went for treatment or from that anesthesia, what we needed for that claim was the explanation of benefits essentially just showing us that Aetna did contribute to it that's all that we needed um yes I know that's really confusing.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, because from what they were telling me, yeah, OK, now I get it. From what they were telling me, um, I think the anesthesia claim was like, like $3000 and something and Ena paid 238, and what Ana didn't pay was the $1500. So you need an explanation of benefits, um, showing, um, what Ana paid and what and and the patient's responsibility, right? And once I send that to you.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes.
[AGENT][POSITIVE] That is correct.
[AGENT][NEUTRAL] Right, um, that is what we need to file these claims mhm so I do see that original claim um that you had sent uh originally that you filed, um, and yes, for those notes what they sent did come back as a duplicate because obviously you had tried to file already and you know.
[CUSTOMER][NEUTRAL] So once I send that to you, OK, OK.
[AGENT][POSITIVE] What we were saying is that it does need the explanation of benefits from your major medical so that's where that confusion is again I apologize you're kind of stuck in the middle of this, but hopefully this kinda helps shed some light if they're able to give it to us that's perfectly fine if not you can get that explanation of benefits from the provider you shouldn't have to get it from Aetna you should be able to give it to them.
[CUSTOMER][NEUTRAL] Yeah, yeah, I, I should be able to get it online. Hm?
[AGENT][POSITIVE] Absolutely, absolutely, and then once you have that you can send it to us and that we should be able to continue getting it processed.
[CUSTOMER][NEUTRAL] So once I get that.
[CUSTOMER][NEUTRAL] OK, so I, I could upload it on, on the, on the, on the site on the portal as well, right?
[AGENT][NEUTRAL] Yes.
[AGENT][POSITIVE] Absolutely, absolutely.
[CUSTOMER][POSITIVE] Good
[CUSTOMER][NEUTRAL] OK, um, and then so it's just uh just the EOB and that's it, that's all I need.
[AGENT][NEUTRAL] That's all that it's saying that's missing, yes.
[CUSTOMER][NEUTRAL] Yes, OK, um, and then do I, so for that amount, do I, uh, uh, do, do you guys submit payment to, to Ambition or like payment to me like we did for the hospital payment to me and then I pay Ambition like or or you submit payment to them directly.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It depends
[AGENT][NEUTRAL] Sure, it really depends on who files the claim. So if you were to file the claim we would send that money directly to you and then of course you can send it to them if they were to be the excuse me, they were the ones to send us file the claim, send us the EOB uh everything that we need, we would go ahead and give it to them.
[CUSTOMER][NEUTRAL] OK, and it looks like they were the ones that filed because I didn't even know the amount it looks like they were the ones that filed the claim.
[AGENT][NEUTRAL] Well, you, you did file it first, um, but it's again we don't have any completed information so at this point it's really going to be whoever gives us the EOB um so you filed the claim first when they filed it registered as a duplicate because you did try to file it first but we were missing that EOB so we were unable to pay it.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Right, OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, OK, so I will send, uh, I'm just, I was just thinking of like next steps to make sure I got it all down. I will send the EOB uploaded to the portal and then, um, should I just give them a call or just wait and give you guys a call back to make sure that you received it and then you could let me know um what uh like what to do from there.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Oh, sure.
[AGENT][NEUTRAL] Yeah, so if you use the um online portal that is going to generally the quickest and easiest way to get claim information to us we usually get it almost immediately so from that point it can take about 7 to 10 business days for claim information to process.
[AGENT][POSITIVE] does not generally take quite that long um but that's just I feel like that's good wiggle room so once you've submitted it you should get a confirmation number that it's been submitted and then of course you can view the status online as well but if you wanted to, you're more than welcome to give us a call any time you'd like to get an update if we've got one available.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Awesome, perfect. Yeah, just to make sure that once it's processed and, and I give you a call back, then you can let me know how to proceed if I have to, if I have to tell the the the anesthesia, um, department to, to submit the claim or if the check is gonna come to me to send to them. So awesome perfect thank you so much for your help.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Absolutely.
[AGENT][NEUTRAL] Yes.
[AGENT][POSITIVE] Absolutely and now I will, yes I will say this, um, just while we're on the phone so that you are aware um you can set up a direct deposit to have that uh benefit amount to be direct deposit into your account.
[AGENT][NEUTRAL] Account your bank account directly um if you don't we would simply just mail a paper check to you which of course can take a bit longer um so if you would like if you're interested in that I can send you a form um for direct deposit that's completely up to you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, mhm.
[CUSTOMER][POSITIVE] Yeah, yeah, if you could send that, that'll be that'll be great.
[AGENT][NEUTRAL] OK, absolutely, give me just a moment. I don't think we have an email for you. um, what's a good email address?
[CUSTOMER][NEUTRAL] Yes, it is [PII]
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] I'm sorry, [PII]?
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII] um.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, hang on just a moment.
[AGENT][NEUTRAL] OK, so that was [PII] you said [PII]?
[CUSTOMER][NEUTRAL] Yes, yes, [PII].
[AGENT][NEUTRAL] [PII], OK.
[AGENT][POSITIVE] Alrighty I will go ahead and get that added to the account and then um I will email you that form just so you've got that um I always feel that's a bit safer and of course much much quicker than a paper copy in the mail so.
[CUSTOMER][NEUTRAL] Mhm, so the form the form I I send it out and I upload it in in the photo too.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] You can actually for the for the direct deposit form you can fill it out through your browser um and then you could just email it right back to us that's perfectly fine.
[CUSTOMER][NEUTRAL] Or is it like a like a link?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][POSITIVE] Oh, OK, awesome OK perfect.
[AGENT][NEUTRAL] Yes.
[AGENT][NEGATIVE] All right, did you have any other questions for me? I know this is all extremely confusing and
[CUSTOMER][NEUTRAL] No, I'm just
[CUSTOMER][POSITIVE] Yeah, thank you so much. Do you have uh um any like an extension in case I, I, um, I wanna follow up. I could talk to you again because you've been so nice.
[AGENT][NEUTRAL] Oh,
[AGENT][POSITIVE] That's really sweet. Um, I don't, um, my name is [PII], um, but I do promise everyone else on the care team is really nice too, but, um, if you would prefer, I am [PII], so assuming I'm available I would love to be able to help you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] OK awesome thank you so much I'll go ahead and I'll get that taken care of and and follow up if if any any questions.
[AGENT][NEUTRAL] Yes.
[AGENT][POSITIVE] Absolutely.
[AGENT][POSITIVE] Sounds good. Well, thank you for giving us a call. I hope you have a great rest of your day. Thank you bye bye.
[CUSTOMER][POSITIVE] OK, thank you so much have a great day.
[CUSTOMER][NEUTRAL] You too. Bye-bye.