AccountId: 011433970860
ContactId: fa4cfa4d-51a9-4e09-8f89-ff9d65f28105
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 886950 ms
Total Talk Time (AGENT): 428851 ms
Total Talk Time (CUSTOMER): 213040 ms
Interruptions: 1
Overall Sentiment: AGENT=0.2, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/14/fa4cfa4d-51a9-4e09-8f89-ff9d65f28105_20250314T12:41_UTC.wav
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[AGENT][NEUTRAL] APL, this is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hey, this is [PII]. How are you?
[AGENT][NEUTRAL] I'm good. What's your name again?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK [PII], how can I help you?
[CUSTOMER][NEUTRAL] I'm calling. I, um, did a claim for a surgery I had last year. I don't know if it looked like it was denied or what it was. I don't know.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Can you help me with that
[AGENT][NEUTRAL] And so take a look at that claim.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, we can do that. What's your policy number?
[CUSTOMER][NEUTRAL] It was 2,463,290.
[AGENT][NEUTRAL] Do you have a claim number?
[CUSTOMER][NEUTRAL] 357-539-6
[AGENT][NEUTRAL] And what's a good phone number, [PII] in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, give me one moment to pull up your file, OK?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII], verify your date of birth, your mailing address, and then your email address for me.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] All right, thank you for verifying that for me. And we're looking at claim 357539.
[AGENT][NEUTRAL] 6
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] OK, so based on the documents that you sent us.
[AGENT][NEUTRAL] Um, the explanation says that most of those charges were paid in full by the primary insurance, so there was nothing for us to pay. Um, I do show one procedure on there. It's the facility charge, um, and we're requesting a copy of the major medical explanation of benefits for that, for that charge.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, you said that was for what?
[AGENT][NEUTRAL] It's a facility charge. It's from Cleveland Clinic, Florida, and it's for a date of service [PII].
[AGENT][NEUTRAL] So it's a hospital charge.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] [PII] or [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK. OK, so like what?
[AGENT][NEUTRAL] Yeah, you
[AGENT][NEUTRAL] Yeah, you, what you sent in, um, we have to acknowledge everything that you sent in to us and so it was a collaboration of years.
[AGENT][NEUTRAL] Um, there, there were some [PII] charges, [PII] charges.
[CUSTOMER][NEUTRAL] I think
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, let's see. Those were not payable. It looks like Doctor [PII] maybe?
[CUSTOMER][NEUTRAL] So what I was
[AGENT][NEUTRAL] Doctor [PII]
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Um, no, not Doctor [PII]. Yeah, Doctor [PII], Doctor Sales. Treatment in the office is not covered under your policy, so there was no payment made on those.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right, I understand that. What I was looking at was the date of [PII]. I had a surgery, out outpatient surgery.
[AGENT][NEUTRAL] And then the
[AGENT][NEUTRAL] You know what, that is [PII]. What did I say? [PII]?
[CUSTOMER][NEUTRAL] [PII]. Mhm.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So for that charge, North Florida surgeons, that date of service is [PII], and we need a copy of the primary explanation of benefits.
[CUSTOMER][NEUTRAL] From the doctor.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK. All right, so what they gave me.
[AGENT][NEUTRAL] Let me go back because I promised I saw one for the hospital for [PII]. Maybe not.
[AGENT][NEUTRAL] There is not one for [PII]. I don't know what I was looking at.
[AGENT][NEUTRAL] So you would call the North Florida surgeon's office?
[AGENT][NEUTRAL] Not the North Florida surgeon's office. You call your primary insurance company or you can download the ELB from their website.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, that's what I got this from.
[AGENT][NEUTRAL] You got what from where?
[CUSTOMER][NEUTRAL] There's explanation of that.
[AGENT][NEUTRAL] What did you get?
[AGENT][NEUTRAL] For 10 6
[CUSTOMER][POSITIVE] Yes, I got it from you now.
[AGENT][NEUTRAL] OK, did you send it in with the documents you just you sent previously or did you just download it?
[CUSTOMER][NEUTRAL] No, the, the ELB that we're looking at, um, that's what I got from the, you know, from United Healthcare.
[AGENT][NEUTRAL] And I'm asking so the the documentations that I'm looking at now, did you include it when you submitted this or you just downloaded it?
[CUSTOMER][NEUTRAL] Yeah, they, no they're all together.
[AGENT][NEUTRAL] OK, we don't see the primary for the 1016, 24.
[CUSTOMER][NEUTRAL] And I said
[CUSTOMER][NEUTRAL] I sent in the um
[CUSTOMER][NEUTRAL] Documents from the doctor with all the
[CUSTOMER][NEUTRAL] Coats and stuff on it.
[AGENT][NEUTRAL] So the charge
[CUSTOMER][NEUTRAL] It should be 3.
[AGENT][NEUTRAL] So the chart we're looking at from North Florida surgeons is $4,549.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Is that what the EOB says the total charges?
[CUSTOMER][NEUTRAL] 444559 is what I see.
[AGENT][NEUTRAL] OK, that's what we show as a bill charge. Let me go back. Give me a second.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And look at the documents that was sent in.
[AGENT][NEUTRAL] Was the service in an outpatient facility or in a doctor's office?
[CUSTOMER][NEUTRAL] You're a hospital.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Still looking.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][POSITIVE] What you send is very organized. I like that. It's not all mixed together.
[CUSTOMER][POSITIVE] Oh thank you.
[CUSTOMER][NEUTRAL] I try.
[AGENT][POSITIVE] appreciate it.
[CUSTOMER][NEUTRAL] Right
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] Yeah, I see a document that shows North Florida surgeons. It gives that amount that we talked about, but that's not the EOB. That's from the doctor's office looks like. Let me keep looking.
[AGENT][NEUTRAL] It says claim form at the upper left is this what you're saying is the EOB?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] That's what the itemized bill that they gave me at the doctor's office.
[AGENT][NEUTRAL] OK, so what we need is United Healthcare's explanation of benefits.
[CUSTOMER][NEUTRAL] And that's the first one.
[CUSTOMER][NEGATIVE] I'm, I'm, I'm so confused.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Yeah, this is not the primary EOB um because it doesn't show, uh, like a deductible co-insurance copay column it usually shows, yeah, this is not, this is, it's from the doctor's office and it looks like they just mimicked the information perhaps that was on the ELB we need the actual ELB from United. Let me keep looking.
[CUSTOMER][POSITIVE] OK, sounds good.
[CUSTOMER][NEUTRAL] So the first, the first, the first document, it should be 4 pages. The first document shows EOB 1016 24 as a PDF file.
[AGENT][NEUTRAL] Mhm, I see that.
[CUSTOMER][NEUTRAL] Uh, from, from United Healthcare.
[AGENT][NEUTRAL] But it's for a different charge.
[AGENT][NEUTRAL] It's for a different it's for a different provider.
[CUSTOMER][NEUTRAL] What ar
[CUSTOMER][NEUTRAL] The anesthesiologist, I think it said.
[AGENT][NEUTRAL] Yeah, it's for 317.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] No, this one shows $3963,936.
[AGENT][NEUTRAL] But that's not this claim. This is the anesthesiologists charge.
[CUSTOMER][NEUTRAL] For the day of my service on the [PII].
[AGENT][NEUTRAL] Well
[AGENT][NEUTRAL] Yeah, I see that.
[CUSTOMER][NEUTRAL] At the hospital.
[AGENT][NEUTRAL] But we're needing, yeah, we're needing the EOB that matches the charge of 4,549.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So, this is, which is the surgeon's charge.
[CUSTOMER][NEUTRAL] OK, what, what, what is it?
[CUSTOMER][NEUTRAL] OK, what is it that you guys actually cover?
[AGENT][NEUTRAL] What do we cover under your outpatient benefit?
[CUSTOMER][NEGATIVE] Yeah, on, on all my benefits cause I'm so confused.
[AGENT][NEUTRAL] OK. What are you confused about?
[CUSTOMER][NEGATIVE] What I, what I, why, why do I have you guys because everything I ever get, I, and nothing ever get, I never, nothing ever happens like I can't, and I don't use you, you understand?
[AGENT][NEUTRAL] So your maximum outpatient benefit uh was $1000 per calendar year and before we can consider a benefit we need the necessary documentation so in this instance we did not receive United's explanation of benefits for this charge. I see some, but they're for other charges.
[CUSTOMER][NEUTRAL] OK, I understand that. I'm talking about for the whole call what is it that?
[AGENT][NEUTRAL] I
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, so your outpatient benefit is up to $1000 per calendar year and then you have an in-hospital benefit if you were admitted it, that's up to $3000 per calendar year.
[CUSTOMER][NEUTRAL] You guys
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And I thought
[AGENT][NEUTRAL] I'm sorry.
[CUSTOMER][NEUTRAL] That's all.
[AGENT][NEUTRAL] Yeah, you have an inpatient and outpatient benefit under the policy that you have.
[CUSTOMER][NEUTRAL] See what I can find for United Healthcare.
[AGENT][NEUTRAL] So the the the EOB that you submitted that that's what we need but we need the one that matches the charge, the 4000 charge.
[CUSTOMER][NEUTRAL] It's available
[AGENT][NEUTRAL] And it should say.
[AGENT][NEUTRAL] Um, like that one says, that's from the anesthesiologist. This one should say.
[AGENT][NEUTRAL] Um, North Florida surgeons on the EOB.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So it's gonna look just like the ones you sent, but the, you know, provider's name and then the total charge is gonna be different.
[AGENT][NEUTRAL] And then we're looking for on that EOB we're looking at the co-pay column, the co-insurance column, and that deductible column and so whatever amount is registered in those three columns is what we will reimburse.
[AGENT][NEUTRAL] To you.
[CUSTOMER][NEUTRAL] Whatever is in those columns in the OK.
[AGENT][NEUTRAL] The deductible, so the amount that says applied to deductible, that column or that co-pay column or that co-insurance column.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] But it looks like you may have met you're out of pocket and they're paying everything at 100%. So this charge may be the same. I don't know. That's why it says 0 in those others because they paid it in full.
[CUSTOMER][NEGATIVE] Mhm, so when they pay it in full, I don't um.
[CUSTOMER][NEUTRAL] You don't pay a benefit?
[AGENT][NEUTRAL] Right, so when they pay it in full, that means that they've resolved all your charges, you don't owe anything and then there's nothing for us to pay and so when I know that there's something for us to pay, it's gonna either show up, they're gonna put it in that deductible column, that copay column or that co-insurance column, and that's what we will pick up for you.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] Or reimbursed to you.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] And it doesn't cover emergency room visits, right?
[AGENT][NEUTRAL] It does. Emergency room is outpatient, so it does cover emergency room.
[CUSTOMER][NEUTRAL] You said 4,559 and do I just resubmit another claim or put it under the one that I just did.
[AGENT][NEUTRAL] Yeah, so you'll have to treat it as a new entry and when we receive it, um, it'll tell us, you know, that we're looking for that ELB under the previous the claim number that you gave me, and we'll just go back and reprocess it as a new claim, so it'll be assigned a new claim number but for the same data service, the same charge.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, so just upload it as a new entry.
[CUSTOMER][NEUTRAL] Yeah, OK.
[CUSTOMER][NEUTRAL] OK, do you want me to upload with the same claim forms as what, uh, I sent with the other one, the claim doc from the doctor?
[AGENT][NEUTRAL] All we need is you know it's ELB so you can just submit that document.
[AGENT][NEUTRAL] And if you want
[CUSTOMER][NEUTRAL] Just the the everything.
[AGENT][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] I think you just need to it'll be nothing else.
[AGENT][NEUTRAL] Correct, and you may wanna put the the claim number on the ELB just write it at the top somewhere, but of course it's yeah and then we'll locate it either way because of the data service and the total charge.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Alright, well thank you for your explanation and your help I appreciate it.
[AGENT][NEUTRAL] You're welcome, [PII]. Did you have any other questions we can help out with today?
[CUSTOMER][NEUTRAL] No, ma'am, I don't.
[AGENT][POSITIVE] OK. All [PII]. Well, thank you for calling ATL. Have a good day.
[CUSTOMER][NEUTRAL] You too. Bye-bye.
[AGENT][NEUTRAL] Uh, bye-bye.