AccountId: 011433970860
ContactId: f791e10b-0b43-4310-8b6a-c2fd6d60b161
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 996549 ms
Total Talk Time (AGENT): 532289 ms
Total Talk Time (CUSTOMER): 450330 ms
Interruptions: 8
Overall Sentiment: AGENT=0.2, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/12/f791e10b-0b43-4310-8b6a-c2fd6d60b161_20250212T21:58_UTC.wav
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[AGENT][NEUTRAL] Afternoon thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII], how are you today?
[AGENT][NEUTRAL] I'm fine, and yourself?
[CUSTOMER][POSITIVE] Not bad at all. My name is [PII], and I am a member and I was calling about a bill that I received that was supposed to be covered through APL.
[AGENT][NEUTRAL] OK, Mr. She
[CUSTOMER][NEUTRAL] Um, I, I do understand, yep, I, I do understand this is, I do understand this is to cover my deductible, and the procedure I had done last year was an outpatient procedure and the way my insurance reads is that I am not responsible for anything after my deductible has been met for outpatient procedures. So I was supposed to pay nothing out of pocket and I've been getting the bill and I called the medical provider and they said they're gonna take care of it and they could see all of that and that was months ago and you know, I'm getting a bill again.
[AGENT][NEUTRAL] I'm sorry, go ahead.
[AGENT][NEUTRAL] OK, Mr. She, so are you trying to find out, so are you trying to find out if we have received a claim for you for a particular data service?
[CUSTOMER][NEUTRAL] So I'm just trying to clear that up.
[CUSTOMER][NEGATIVE] Um, yeah, well, and I guess so the total amount billed was $1500 for the outpatient procedure, and I wasn't supposed to pay anything out of pocket because all that was supposed to go toward my deductible. And now here I sit with a $276 bill, and it shows on here that insurance covered $1,224 of that, and the other 276 are saying I'm responsible for.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] OK, Mr. [PII], so I'll be glad to help you with this to see if we've received a claim for you. So first off, what is a good callback number for you?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. And what is your policy number, please?
[CUSTOMER][NEUTRAL] My policy number.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] It would be on your ID card.
[CUSTOMER][NEUTRAL] Is that, is that, is that the is that the group number?
[AGENT][NEUTRAL] No sir, there will be another number on the front of your ID card, and it depends on the type of plan you have as to how it would be worded. You may have an in-hospital or an outpatient number.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes, so I've got, yep, I've got both in hospital and both outpatient. You want the outpatient?
[AGENT][NEUTRAL] OK. If you'll notice Mr. Sheep on both of those numbers, the very beginning is identical prior to the ML.
[CUSTOMER][NEUTRAL] All this is just the last, yep, last digits the only thing differs.
[AGENT][NEUTRAL] So I just, mhm, and that only differentiates inpatient and outpatient. So all I need is the first part of that number before the letter M.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That is 14.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 79793
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, thank you. So if you'll give me a moment please to get your information uh pulled up and then once I do, Mr. [PII], yeah, thank you very much. I will have to verify several things with you for security purposes and then also any information that I do provide for you today will be a verification of benefits and not a guarantee of payment.
[CUSTOMER][POSITIVE] Mhm. Yeah, absolutely.
[AGENT][NEUTRAL] So first off, if you will please verify your date of birth.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you, excuse me, and your home mailing address.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you. The phone number that we have on file for you is the same as the one you gave me, so again that is your best contact number, is that correct?
[CUSTOMER][NEUTRAL] Yes, that's the number I'm calling from now.
[AGENT][NEUTRAL] OK, thank you and then the email address that we have on file appears to be your work email?
[AGENT][NEUTRAL] What would that have been?
[CUSTOMER][NEUTRAL] Uh, [PII] or [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, thank you. Now, the policy number that you provided for me, Mr. She, this policy was active from [PII]. Let me check about, OK, so you have another policy that, yes, you have a.
[CUSTOMER][NEUTRAL] Uh, so this
[CUSTOMER][NEUTRAL] So this, this may be an old card.
[AGENT][NEUTRAL] Yes, sir, it is. Um, I can give you your new policy number, the one that's been in effect since [PII].
[AGENT][NEUTRAL] And then I'm also going to email you the instructions for our portal and how to set up your profile because once you do that that will give you access to your ID cards, your policy information, and also any claims information that we have on file for you. So your current active policy, Mr. [PII] is 01.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 71
[AGENT][NEUTRAL] 9350.
[CUSTOMER][NEUTRAL] Got it.
[AGENT][NEUTRAL] And again this is the one that is currently active now is that email address that we just verified, is that still a valid email for you?
[CUSTOMER][NEUTRAL] It is.
[AGENT][NEUTRAL] OK, alright, so I will email you that user guide in just a moment.
[AGENT][NEUTRAL] The email too that you're gonna receive from me, it will come from [PII] at [PII].
[AGENT][NEUTRAL] And also I will put in the subject line for you APL online service center so that she can recognize that as not being some form of junk mail or spam.
[CUSTOMER][NEUTRAL] Yes, it seems more and more that is going on nowadays.
[AGENT][POSITIVE] Yes, sir, and you can't hardly stop it.
[CUSTOMER][NEUTRAL] No, I know, and it's, it's really getting to the point where it's, it's getting, you know, people, people aren't aware of it anymore in the depth and the scope that it's going now and yeah, so I, yeah.
[AGENT][NEUTRAL] Correct. Yes, so that's why I try to tell my callers that I speak with what to look for, you know, um, in their email for this. OK, so I'm gonna go ahead, I'm sending this now.
[CUSTOMER][NEUTRAL] Yep.
[AGENT][NEUTRAL] So you should have that in just the next minute or so. Um, now, in looking at both of your policies, even the old one.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] We do not have any, we've never received any.
[AGENT][NEUTRAL] Claims for you.
[AGENT][NEUTRAL] From any provider.
[CUSTOMER][POSITIVE] Interesting.
[CUSTOMER][POSITIVE] Interesting.
[CUSTOMER][NEUTRAL] Hm, yeah, because so.
[AGENT][NEUTRAL] Now, the good thing about APL Mr. She is that we don't have a timely filing limit. So the claims can still be submitted to us either by the provider or by you. Mhm.
[CUSTOMER][NEUTRAL] No home
[CUSTOMER][NEUTRAL] This
[CUSTOMER][NEUTRAL] This was actually done at the end of [PII].
[AGENT][NEGATIVE] Yes, so we've never received anything.
[CUSTOMER][NEUTRAL] So this has been almost a year now, yes, so I would, I would suspect that it would have been in that new policy if anything.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, sir, and I've looked at both. I'm looking at your new policy currently.
[CUSTOMER][NEUTRAL] Hm
[CUSTOMER][POSITIVE] That is, that is really, really interesting. Yeah, so my primary medical is through Cigna, um, underwritten through Health Easy.
[CUSTOMER][NEUTRAL] And I don't, I don't know, uh, you probably can't see that information, um, but yeah, so on that policy there, it showed cause this was an outpatient procedure, um, it was gastrointestinal, um, I had a colonoscopy done.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] And being it was outpatient under that Health Easy, it says that I'm um for any outpatient service that I'm not responsible for anything out of pocket after my deductible's been met. So I normally would have been paying that out of pocket, but because I had the APL that was supposed to go towards my deductible, that $1500. So this is really interesting because I wonder who paid the 1224.
[AGENT][NEUTRAL] Mm, and I can't I.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] I can't know that one. I don't have the answer to that one, Mr. [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So again the claim can still be filed with APL and you may want to reach out to your provider for that data service to see if they will file it.
[AGENT][NEUTRAL] If for any reason they won't, you can submit the claim to us yourself.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Give me just a moment.
[AGENT][NEUTRAL] You can get this claim form from our public website.
[AGENT][NEUTRAL] But I can also just send you a separate email with the claim form in case you you end up filing it yourself because it has instructions on it for the other documentation that you will also need to have.
[AGENT][NEUTRAL] To file this type of claim?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So give me just a second and I'll send you that as well.
[AGENT][NEUTRAL] If the provider would do it for you, typically that's gonna be an easier route.
[AGENT][NEUTRAL] But
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Because you're still gonna have to get an itemized bill that includes your diagnosis and procedure codes from your provider.
[AGENT][NEUTRAL] In addition to your primary insurance company's explanation of benefits.
[CUSTOMER][NEUTRAL] Yeah, you know, it's interesting because I had already asked um the place um this was Gastro Health LLC that I went to the provider and I've already asked them for an itemized bill, you know, they told me they couldn't give that to me.
[AGENT][NEUTRAL] Really?
[CUSTOMER][NEGATIVE] That's exactly what they told me, yes, and I even said the same thing. I, I, I said, you're, you're kidding me, right? This is my bill. You can't give me an itemized bill and a breakdown of the charges and what they were for, so I can make sure that this is because I knew that I couldn't just come to you guys without having that information, but I said the only thing I.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] See here on the bill is for the gastrointestinal procedure. They do have a code here, 45378 beside it. I, I don't know if that's the coding for it or not, but the amount billed was $1500 and it shows insurance covered 1,224 and the amount remaining is 276.
[AGENT][NEUTRAL] Hm, uh, OK.
[CUSTOMER][NEGATIVE] Very, very strange. I didn't expect to, to run across this at all. I thought you guys had paid the $1224 because from what I understood, that was the way it was supposed to go. And then I was still, they even told me that I would have like $4000 some odd dollars left on my deductible still for that calendar year.
[AGENT][NEUTRAL] Um, OK.
[CUSTOMER][NEUTRAL] Now, now this was at that, this was at that time I had the procedure.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right, is what, this was what they thought and it all made sense because sure I look at my insurance, you know, through Health Easy and it shows for any outpatient procedure, you know, I'm responsible or I'm not responsible for anything, um, and if my deductible has been met for that outpatient procedure and which you guys supply the coverage for the deductible, so.
[CUSTOMER][NEUTRAL] Yeah, very, very odd.
[AGENT][NEUTRAL] Yes, and on this, so yes, sir. I, you would just have to um reach out to them again, again.
[AGENT][NEUTRAL] Because on this policy, you know, your outpatient calendar, your benefit max for covered outpatient services is $6600 with no outpatient deductible.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] So, but we would have to receive, you know, the claim again with the itemized bill including diagnosis and procedure codes and a copy of your primary insurance company's explanation of benefits showing any of the co-pay, any amounts applied to your co-pay, deductible or co-insurance amounts.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] OK, so.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, but you do see it on your end for that procedure that what I'm telling you sounds correct, right? I mean, I'm not under any misinterpretation or anything like that, and, and I know whenever we got on the phone.
[AGENT][NEUTRAL] That is a, I mean, it's.
[AGENT][NEUTRAL] A scope on an outpatient basis.
[CUSTOMER][NEUTRAL] Well I know whenever you get on the phone that that's not a guarantee of payment, so I, I understand that and I'm not asking that, but yes.
[AGENT][POSITIVE] Correct. Yes, sir.
[AGENT][NEUTRAL] But a colonoscopy is something that we could review.
[AGENT][NEUTRAL] Under your outpatient benefits. So yes, sir.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. Yeah, so the reason why, yeah, the reason why I had to have the colonoscopy because I was um diagnosed with diverticulitis.
[AGENT][NEUTRAL] We could review that.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I went into the emergency room with abdominal pain and the colonoscopy followed because of the diverticulitis.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. So, so we haven't.
[CUSTOMER][NEUTRAL] I've never had one before.
[AGENT][NEGATIVE] Right, and we didn't even receive a claim for your emergency room visit.
[AGENT][NEUTRAL] We don't have any claims on file for you on either one of your policies.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, yeah, and typically a tip would you guys normally receive that kind of claim being that I would just have a copay through my primary insurance and APO would be wouldn't be responsible for any of that anyway?
[AGENT][NEUTRAL] If you've
[AGENT][NEUTRAL] Well, if you, if you.
[AGENT][NEUTRAL] If you presented your APO information and your primary health care insurance information.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Most providers will file both and if they don't, they typically will tell you that we will only file your primary, you know, and then you would be responsible for filing it with us.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So it, and again we don't have any say in how they handle that, you know.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Yes ma'am. I, yeah, I understand, I understand. So based on what would be your advice, right? Should I go back to Health Easy and Cigna and say, hey, who paid this 1224 and, and, and open up that can of worms, or should I just go back to the provider, give them the new policy number, which I think may have been one of the problems originally, give them the new policy and ask them to file for the 276, would that be my path of least resistance on this?
[AGENT][NEUTRAL] I would, I believe that first off, as far as filing a claim, yes, sir, I would personally reach out to the provider.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] To see if they will do it since we don't have a timely filing limit and then if they do not, then I mean if they say no you know it's for whatever reason no then you can file it and you can use that claim form that I emailed you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK. Sure, but in order for me to
[AGENT][NEUTRAL] As to have your instructions. You still have to get all the information.
[CUSTOMER][NEUTRAL] Yeah, but in order for me to file it.
[CUSTOMER][NEGATIVE] Exactly, that they told me they couldn't provide to me.
[AGENT][NEUTRAL] I
[AGENT][NEUTRAL] So that may be, you know, that's kind of a, a quagmire right there, but, um,
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] Uh, I'm not sure why they told you that. I, I can't, uh, I mean, I just don't understand that, but.
[CUSTOMER][NEUTRAL] And I didn't either. And, and I wasn't, you know, whenever I'm on the phone and stuff like this, right? I try not to get upset because I know it's not you that, you know, I should be upset with you're, you're trying to help and I'm sure that this person was too, you know, so, you know, it's one of those things where it's like, that doesn't sound right, but I'm not gonna argue with you because
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And honestly,
[AGENT][NEUTRAL] Right. And see, honestly, I can see.
[AGENT][NEUTRAL] You know, last year, what date exactly did you have your s[PII] again? You said it was the end of March.
[CUSTOMER][NEUTRAL] [PII] was the date of the service on this invoice.
[AGENT][NEUTRAL] OK, so I can see where
[AGENT][NEUTRAL] A provider
[AGENT][NEUTRAL] Um, called on like [PII] to verify your benefit information, and that was on this current policy under the correct number because even if, even if a provider has the incorrect policy number, Mr. [PII], if you have another policy that's active, we'll cross reference that and try to give them the correct policy number and information. So I do see that they call, someone called for benefits.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so,
[AGENT][NEUTRAL] For outpatient benefits. Mhm. But
[CUSTOMER][NEUTRAL] On the [PII], OK.
[AGENT][NEGATIVE] That was the last communication. There was never any claim received.
[AGENT][NEUTRAL] For you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, interesting. So it sounds like whatever they did, they didn't go about it the right way.
[AGENT][NEUTRAL] It sounds like something may have just, you know, fallen through the cracks somewhere. Obviously, since we never received the claim.
[CUSTOMER][NEUTRAL] Yeah, OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All right, well let me call them and let's see if I can't get this squared away and [PII], I thank you so much for your help. I do appreciate it and um I hope you have a.
[AGENT][NEUTRAL] Well, you are certainly
[CUSTOMER][POSITIVE] I hope you enjoy the rest of your day and um yeah I said you've been a big help thank you.
[AGENT][NEUTRAL] I
[AGENT][POSITIVE] Well, you are very welcome and if there's any other questions, if anything else comes up, please give us a call back and we'll be more than happy to help you.
[CUSTOMER][POSITIVE] Will do. Thank you.
[AGENT][POSITIVE] OK, well, you're very welcome and thank you again for calling APL. Have a wonderful evening.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] All right you as well.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Bye-bye.
[AGENT][NEUTRAL] Bye bye.