AccountId: 011433970860
ContactId: fad208f9-e40f-4fe1-afde-740b001d7e95
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 628739 ms
Total Talk Time (AGENT): 306381 ms
Total Talk Time (CUSTOMER): 246333 ms
Interruptions: 5
Overall Sentiment: AGENT=0.5, CUSTOMER=1.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/24/fad208f9-e40f-4fe1-afde-740b001d7e95_20250324T14:24_UTC.wav
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[AGENT][NEUTRAL] Contacting ATL, my name is [PII]. How may I help you?
[CUSTOMER][POSITIVE] Yes, hi, good morning. How are you?
[AGENT][NEUTRAL] I'm fine how are you?
[CUSTOMER][POSITIVE] I'm good. Thank you for asking. OK, do you want my benefit number?
[AGENT][NEUTRAL] Yes, please.
[CUSTOMER][NEUTRAL] The card, the insurance? OK. It's 02.
[CUSTOMER][NEUTRAL] 55
[CUSTOMER][NEUTRAL] 277
[CUSTOMER][NEUTRAL] 9
[CUSTOMER][NEUTRAL] NL 7.
[AGENT][NEUTRAL] Thank you. If I could verify your name, uh date of birth, and a phone number, please.
[CUSTOMER][NEUTRAL] My name is [PII].
[CUSTOMER][NEUTRAL] And uh date of birth April.
[CUSTOMER][NEUTRAL] Uh, [PII].
[AGENT][NEUTRAL] OK, [PII]. Thank you. And the phone number, please?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] Thank you, [PII]. I have your policy pulled up. How may I help you?
[CUSTOMER][NEUTRAL] Actually, I'm calling about the claim. I, I, I applied uh for my daughter, for [PII]. I submit, he did the surgery.
[CUSTOMER][NEUTRAL] On [PII]. And before the [PII], they gave me the estimate of the, the surgery was 18,000, like the paper I already submit. And they told me I have to pay the difference, the uh 2900 something. So, that's all the paper I submit for the, the, with the claim the first time.
[CUSTOMER][NEUTRAL] And then when I called, because it was processed, but it looks like it doesn't take any action or need more information. So when I called back, they said you have to provide the insurance, the share, your share and what the insurance is gonna pay.
[CUSTOMER][NEUTRAL] And that's what exactly I did, but it looks like I have, they submitted more payments for than the one they gave it to me on the [PII]. And what the share of my part, it should be is gonna be more than what I paid. So, now, when I open the documents about my claim,
[CUSTOMER][NEUTRAL] Uh, they said, um, the, the paper I provided is not matching or the number is not delegated with the, the, with the insurance. So, you need more explanation about the benefits I show, but how can I do that?
[AGENT][NEUTRAL] Yes.
[AGENT][POSITIVE] Yes, absolutely, so I have it pulled up.
[CUSTOMER][NEUTRAL] I exactly told you what, what I, what exactly happened. Like, they gave me the paper I submitted, when you, when you open the file I submitted. This is the paper, they gave it to me before my daughter go into the surgery, and they asked me, I have to pay that before she got in.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] And I paid it, and you can see I paid it with uh my credit card and I can submit it also the statement, if that's gonna prove what I did.
[AGENT][NEGATIVE] Oh, no, no, we don't need that. No. No, ma'am, we don't need that. Um.
[CUSTOMER][NEUTRAL] So, but I don't know, I don't know why it looks like different. It's, it makes sense, but for you, what you're saying, but for me, what can I do? Because it looks different, but
[AGENT][POSITIVE] Yes, of course.
[AGENT][POSITIVE] I can help with that.
[CUSTOMER][NEUTRAL] What can I do now?
[AGENT][NEUTRAL] OK, so I'm looking at it now. Um, so, what you have is an is, uh, your explanation of of uh explanation of benefits from Aetna.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] And I'm looking at it now and so what you turned in, um, sometimes it's kind of, it's, it's kind of um
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Uh, let's see what's strange here. Let's see.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] What we have is we have three different services and it looks like your share is that your your your total share is $5,673.93 but it's for 4 services or 3 or 4 services that we have here. And so your explanation of benefits that we're looking for.
[AGENT][NEUTRAL] Um, actually tells us how much to pay towards each service. So, so you, you have, you have the page that you sent us, and then on the explanation of benefits from Aetna, and they will send this to you or you can find it on your portal, the Aetna portal, you know, where you actually you you um go in there and look at your base. So what it will have on there is, uh, for, um.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Uh, the, um, orthopedic Florida orthopedic surgery, there was one, procedure that cost $8640. So on that, it will say, uh, for that particular procedure, we have put this much towards your deductible, however, however much of a dollar amount, and what it will say on that EOB is deductible, co-payment, or co-insurance, but it will specifically, uh, it will specifically um state this particular one.
[AGENT][NEUTRAL] Now what we have is where it shows your your plan share and your plan discount but it doesn't actually tell us how much to put towards each individual um uh charge but you do have that it it it's you're um you know we have everything else so what we're looking for is how much do we put towards uh um each uh.
[AGENT][NEUTRAL] Each um charge and that's that is really what we're looking for here is how much do we put towards each charge and uh and that's the only thing that we're really looking for. So you, you have sent us the you have sent us part of it. Mhm.
[CUSTOMER][NEUTRAL] But, but how, how can we, how?
[CUSTOMER][NEUTRAL] How I can do that? I'm opened the portal now, OK, when I'm talking to you now, I open the portal. But there, that doesn't show the one I sent it to you, the [PII].
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] It's
[CUSTOMER][NEUTRAL] But I believe this is the one I sent if you go through the, the, it, it shows, it's what the amount go each one, because one of them, it's 8600, and one of them it's 11,000. Under each one of the scroll of the operating, like, if you open and scroll, this is the one I, I send it. Do you want me to download it again?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, uh-huh.
[AGENT][NEUTRAL] No, no, I've got it. I've got it. I'm looking straight at it. So what is it's saying on here, um, so, uh, so let's see.
[AGENT][NEUTRAL] The one for, let's see, let me just check here. Excuse me just a moment, please.
[CUSTOMER][NEUTRAL] I have the statement, it just got in because it wasn't before, you know, it's just everything processed. Do you want me to send it?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] No, ma'am. No, that wouldn't, that should, that should not be ne uh it's just, I'm just trying to see what, cause it does look like there's something on here that we need to have, um.
[CUSTOMER][NEUTRAL] Or
[AGENT][NEUTRAL] And I'm, I apologize, my computer is just a little bit. Yeah, excuse me, just a moment, please. I'm, my computer is just a little bit slow. I'll be right back.
[CUSTOMER][POSITIVE] Thank you for your help.
[CUSTOMER][POSITIVE] Uh, take your time, take your time.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, so what we, what we would be looking for, um, is this, uh, the, the, the one for 11,000, is that a, uh, is that a facility bill or what is that for?
[CUSTOMER][NEUTRAL] OK, let me open for you. Uh, OK. The [PII], the [PII], the, the total 29th for the one I sent it to you, it's coming for the surgery center.
[AGENT][NEUTRAL] Is that for everything?
[AGENT][NEUTRAL] Yeah. Well, I, well, no, it's.
[AGENT][NEUTRAL] Uh, yeah, the uh uh.
[CUSTOMER][NEGATIVE] I don't know, I, I'm, I'm not good about that, no, scroll for, uh, the 110 and the scroll because she had two scrolls in, in, in her hand.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] I see.
[CUSTOMER][NEUTRAL] I don't know. This is.
[AGENT][NEUTRAL] Well, let me, let me go ahead and send this back. Um, I do see what you sent. Uh, let me send it back towards the, uh, to the, um, to the, uh, pro I mean to the examiner. Um, normally what we ask for is something that shows the deductible, co-payment or co-insurance for each one, but [PII], please let me send this back to the examiner to see what we can do with this and, and whether we can get this taken care of because it does show that, uh, that you do have the, at least that usually the diagnosis code that you did what we're looking for, it looks like we've got that.
[AGENT][NEUTRAL] So if you don't mind, um, I'd like to send this back and, and see if we can't get this processed, OK? Now if we are unable to do so, we will contact you and, and let you know, um, but normally, uh, the Aetna will have a, a more detailed, uh, uh, explanation of benefits, but if we don't have that, then, you know, if I mean if we do end up needing that, then we'll certainly let you know, um, but let me at least check this and see whether um.
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Whether this is something that we can uh
[AGENT][NEUTRAL] That we can do.
[CUSTOMER][NEUTRAL] Do you want any also submit the new statement for March?
[AGENT][NEUTRAL] Well, I don't, I don't know. Yeah, I'm not really sure whether that will help or not, um, because it may end up being that what we need to do is, um, is this, uh,
[CUSTOMER][NEUTRAL] Is that gonna help?
[AGENT][NEUTRAL] It looks like what we may end up needing is, is a more detailed explanation of benefits, but if we don't, if we don't, then, then, uh, you know, that's fine. We can go ahead and, and, uh, and, uh, process it. But if we do, uh, if we do need any more documentation, then we can contact you and let you know. But let me send this back and see if this can actually be processed the way it is.
[CUSTOMER][POSITIVE] OK. Thank you so much. Thank you. I really appreciate it.
[AGENT][NEUTRAL] OK, well, is there anything else that, anything else that I can help with?
[CUSTOMER][POSITIVE] No, thank you. Thank you so much.
[AGENT][POSITIVE] OK, thanks for contacting ATL. Thank you for contacting us. You have a very good.
[CUSTOMER][POSITIVE] I appreciate your help.