AccountId: 011433970860
ContactId: f9eb6f3a-8354-41d1-9663-de552b7a08c0
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 632460 ms
Total Talk Time (AGENT): 229123 ms
Total Talk Time (CUSTOMER): 247154 ms
Interruptions: 0
Overall Sentiment: AGENT=1.4, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/02/f9eb6f3a-8354-41d1-9663-de552b7a08c0_20250102T16:03_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Uh, yes, [PII]. My name is [PII].
[CUSTOMER][NEUTRAL] Uh, what is, what would you need to, uh, you would need the policy number?
[AGENT][NEUTRAL] Yeah, we can start with your policy number, [PII].
[CUSTOMER][NEUTRAL] 02502554
[AGENT][NEUTRAL] All right. Let me pull that up here. One moment.
[AGENT][NEUTRAL] All right. And then if I could verify please your date of birth and address.
[CUSTOMER][NEUTRAL] My date of birth is [PII].
[AGENT][NEUTRAL] Thank you and the address we should have on file?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you and the [PII] [PII] is that still a good email for you?
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] Yes, yes.
[AGENT][POSITIVE] OK. How can I help today?
[CUSTOMER][NEGATIVE] Yes, I had a surgery on [PII], which I sent you guys several claims. Uh, they, they keep sending me bills. I have a bill for the, for [PII], which my party is $425.43 which is the uh this is uh uh anesthesiologist for 60 minutes.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, you have it there?
[AGENT][NEUTRAL] Um, let me take a look. I need to find the claim number and let me search that date. You said it was the data service was [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. Yeah, there were a few different claims here. You said it was for anesthesia?
[CUSTOMER][NEUTRAL] Yes, $425.43.
[AGENT][NEUTRAL] Do you have a claim number, anything for what you had received?
[CUSTOMER][NEUTRAL] What is it that you need?
[AGENT][NEUTRAL] I was just wondering if you had a claim number from us.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] I'm looking, I mean the I'm on the website, but and I know I submitted everything in. I don't know.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I don't, I don't.
[CUSTOMER][NEGATIVE] If you don't see it then I, I guess I'm I'm gonna have to resend it in because I, I got 3 bills which I don't understand, which is for the same day.
[CUSTOMER][NEUTRAL] Uh, one of them, which I think you guys pay the doctor for uh.
[CUSTOMER][NEUTRAL] For [PII] for
[CUSTOMER][NEUTRAL] 1,17549, I think.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] You, you don't have it, no?
[AGENT][NEUTRAL] So I see for that date of service there was a facility payment, it looks like to Jackson South Medical for 9/27 [PII] was a facility charge.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEGATIVE] And then it looks like the majority of the claims after that for that date of service were denied. And when I look at
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And the
[CUSTOMER][NEUTRAL] Why were they denied? Do you have any idea?
[AGENT][NEUTRAL] So it looks like the outpatient benefit max for the calendar year had been exhausted.
[AGENT][NEUTRAL] So your outpatient benefit max for the calendar year was 2500, so you had exhausted the entire 2500 for [PII].
[CUSTOMER][NEUTRAL] OK, so, oh, if I exhausted the whole thing then I have, I'm responsible for the out of pocket expenses.
[AGENT][NEUTRAL] Yeah I mean that's up to the facility or provider um you know we don't advise whether or not it's your responsibility if they're sending you a bill for a residual amount then yeah I mean that would be something you would need to take care of with them.
[CUSTOMER][NEUTRAL] Oh, because you guys within a calendar year you guys pay a maximum of $2500 for whatever claims and that includes doctors.
[AGENT][NEUTRAL] For
[AGENT][NEUTRAL] That's yeah for outpatient services that's the max that your plan will pay is 2500.
[CUSTOMER][NEUTRAL] OK, and you guys have paid it for the outpatient services.
[AGENT][NEUTRAL] That's what I'm showing, yes, and that's why any other claims after that were denied.
[CUSTOMER][NEGATIVE] So everything else that you guys got it was denied.
[AGENT][NEGATIVE] Everything, yeah, everything else that I saw for [PII], um, correct was showing a denial. There was a one benefit payment sent it looks like to the facility, the hospital, but that exhausted the residual what you had left for the year that took the rest of it, so there was nothing additional payable.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Um, OK, OK.
[CUSTOMER][NEUTRAL] Got it. OK.
[CUSTOMER][POSITIVE] Thank you, thank you.
[AGENT][NEUTRAL] You're welcome, [PII]. Did you need me to check on anything else for you?
[CUSTOMER][NEUTRAL] I'm a little confused because I have a the doctor charge uh gave me a charge of $1,235 and I don't know if you denied the doctor payment.
[AGENT][NEUTRAL] It was same data service of 927.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] This is to pay the doctor.
[AGENT][NEUTRAL] Um let me see.
[CUSTOMER][NEUTRAL] The original amount he charged was 2,546.51. That was him, his service.
[AGENT][NEUTRAL] Let me see if I can find a charge amount for that much.
[AGENT][NEUTRAL] And the closest thing I see as far as billed amount is 1260, you said it was 1,235.
[CUSTOMER][NEUTRAL] See, I'm confused because there's a charge of 1,23549 and another charge of 1,323. 75, but I don't think you have those charges like that there.
[AGENT][NEUTRAL] Probably not because generally they send us the billed amount after your primary, so whatever your primary covered, then they send us, you know, um the residual, the difference, do you know if that was the amount after the primary pay or?
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] I guess it's yeah I'm, I'm going to call them directly and what I can do.
[CUSTOMER][NEUTRAL] So I can get some clarity is for them to bill you guys directly. The worst that it can happen is that you guys deny it, I guess, correct?
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Right, no, yeah, you're exactly right. Yeah, exactly right. So, yeah, the only
[CUSTOMER][NEUTRAL] OK, let me ask you.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, let me ask you, I understand the facility, but the as far as the doctor procedure, that's another amount or it that's included in the yearly calendar?
[AGENT][NEUTRAL] Well, if the procedure that you had done was outpatient, then it would lump into your outpatient benefits. The only way it would be different is if you were actually inpatient, meaning in the hospital for like 18 hours, then that would fall under inpatient. And that's a different amount.
[CUSTOMER][NEUTRAL] On
[CUSTOMER][NEUTRAL] Oh, OK. OK. So,
[CUSTOMER][NEUTRAL] Under, so I can get, I understand, under the umbrella of outpatient, that includes the facility and the doctor that does the procedure.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] That's what you're telling me. Let's say that I, I had a surgery. The surgery was
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] An outpatient surgery, including the doctor and blah blah blah, $8000 the uh the the.
[CUSTOMER][NEUTRAL] Aetna paid X amount of money, but you, the most you guys would be paid, including the doctor that did the procedure and everybody else is the $2500. That's what you're telling me, correct?
[AGENT][POSITIVE] Mhm, correct.
[CUSTOMER][POSITIVE] OK, I think I think I'm I'm understanding. OK, thank you for your explanation. Thank you.
[AGENT][POSITIVE] Yeah, you're very welcome and if you have any other questions or concerns, feel free to give us a call.
[CUSTOMER][POSITIVE] Thank you. Mm bye-bye.
[AGENT][POSITIVE] You're welcome, [PII]. Bye-bye.
[CUSTOMER][NEUTRAL] OK.