AccountId: 011433970860
ContactId: faf472de-e5ed-41fa-a76a-648f535b3e90
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 364420 ms
Total Talk Time (AGENT): 184782 ms
Total Talk Time (CUSTOMER): 167144 ms
Interruptions: 2
Overall Sentiment: AGENT=0.8, CUSTOMER=-0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/17/faf472de-e5ed-41fa-a76a-648f535b3e90_20250317T20:37_UTC.wav
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[AGENT][NEUTRAL] For contacting ATO. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi there, [PII]. My name is [PII]. I'm, I'm calling cause last year I went to two different doctors, one for dermatology and the other one just a regular um general physician, and I have a bill from both of them for the, um,
[CUSTOMER][NEGATIVE] For the copay, um, but I, I don't understand why it's not being covered. I'm hoping you can help me out with that.
[AGENT][POSITIVE] Yes, I can certainly help with that. Um, [PII], if you don't mind giving me your policy number, please?
[CUSTOMER][NEUTRAL] Sure, um, on the card, where would that be? would that be the payer ID or?
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Well, it might say inpatient or outpatient services or um it might be given as a 01 or 02.
[CUSTOMER][NEUTRAL] OK, I see it now, yes, um, outpatient, I, I imagine, um, would be it uh 02568978 M as in Mary, L as in Larry 8.
[AGENT][POSITIVE] I do appreciate that. If I could just have uh verify your date of birth, please, ma'am, and a uh callback number in the event that we're disconnected.
[CUSTOMER][NEUTRAL] Sure, do you want it's through my husband, the, the insurance. Do you want his date of birth or mine?
[AGENT][NEUTRAL] Oh, yours would be fine.
[CUSTOMER][NEUTRAL] OK, it's [PII].
[CUSTOMER][NEUTRAL] And the callback number [PII].
[AGENT][POSITIVE] I appreciate that. Thank you. I'm looking over the benefits now.
[AGENT][NEUTRAL] OK. So it has in and out of hospital settings, um.
[AGENT][NEUTRAL] It looks like it was just for hospital, so let me just check here really quickly, uh.
[CUSTOMER][NEGATIVE] Not, not for my, maybe for him, it wouldn't have been for myself.
[AGENT][NEUTRAL] Well, let's see, I, the last, the last, uh, claim that I have for you is for uh AdventHealth primary care, uh, for, for office visits and treatment within the physician's office. Now, um, it looks like your, your policy had in and in hospitals benefits and outpatient hospital benefits, but there was nothing for um physician's offices at all. So looking at the policy, yes ma'am.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That's the
[CUSTOMER][NEUTRAL] That's really weird because I wasn't in the hospital at all that I went to the, the actual um outpatient office um and I know the bill is $40. I don't know, do you have it as the same?
[AGENT][NEUTRAL] Uh, well, I have very, I mean, there, there are a lot of charges on this. There, there are multiple charges, um, so, uh.
[AGENT][NEUTRAL] It's, I mean that's one of them, but that there were lots of charges that were on here. We just check, uh, so the charges that I have for that date of service, let's just see here, um.
[AGENT][NEUTRAL] So there was uh uh sorry, see. So there was a check, excuse me, a charge for $443 and that was an office visit. This is all AdventHealth Primary.
[CUSTOMER][NEUTRAL] It's fine.
[AGENT][NEUTRAL] Um, there was a charge for uh $382. That was also an office visit. Now, the treatment within the physician's office, and this is, um, uh, what, what we were, you know, that's also on here as well. It doesn't look like that's covered. Uh, it looks like there was um an immunization shot. Uh, it looks, uh, something to do with immunization, um.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Uh, there was also, uh, it looks like there was a, a flu shot, um, but, uh, yeah, those things are not, uh, nothing within a physician's office is covered.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Oh, that, that's weird. It, it was, um, it wasn't in the hospital. I can guarantee that. And it, the, the odd thing is that this has been covered. OK.
[AGENT][NEUTRAL] Oh no, I mean, that's the only, yeah.
[AGENT][NEUTRAL] Yes, see, the only time it would be covered, it would be in the hospital. That's, that's what I meant is that the only time it would be covered, yeah, if you went into the hospital.
[CUSTOMER][NEUTRAL] Oh this is all the
[CUSTOMER][NEUTRAL] Oh, really?
[CUSTOMER][NEUTRAL] Oh wow, that's, that's weird. Did it change because you're, we've had um APL gap insurance for years and I, I, I used to use only um Cleveland Clinic and everything was covered. So it, it's odd that all of a sudden now it's these things aren't being covered, um.
[AGENT][NEUTRAL] Yeah, I guess it just depends on how they bill it because if they bill it as outpatient hospital then it would have been covered.
[CUSTOMER][NEUTRAL] OK. I got, got you. So maybe they did it they did it wrong. They filed it wrong um for outpatient instead of they did in hospital instead of outpatient. Is that what I'm hearing possibly?
[AGENT][NEUTRAL] Well, it's, uh, well, I'm showing that all of these services were for, um, were for outpatient services, but I'm, I'm, I'm thinking that the, it, it would have, if you had gone to Cleveland Clinic and it would have paid, it would have had to have been outpatient hospital. That's the only way that they could bill it that we would have paid it.
[CUSTOMER][NEUTRAL] OK, um, well, I, I'm, I'm, I'm sorry, I'm confused a little bit, but, um, that's fine. So I mean they're sending me a bill for $40 it just that's not something you guys are gonna cover, correct?
[AGENT][NEGATIVE] Uh no, ma'am. That, that would not be covered.
[CUSTOMER][NEUTRAL] OK. And the second one is for um.
[CUSTOMER][NEUTRAL] The dermatology, um, for the office visit, it was 160.
[CUSTOMER][NEUTRAL] That is the
[AGENT][POSITIVE] And what day? Oh, I'm sorry.
[CUSTOMER][NEUTRAL] That was [PII].
[AGENT][NEUTRAL] Uh, I've got something for [PII].
[CUSTOMER][NEUTRAL] Yes, that would be it.
[AGENT][NEUTRAL] Um, for Levitt, yeah, that's, uh, we did receive that, but, um, that was all, it wasn't that a uh office visit, but it was treatment within the physician's office, but that wasn't covered either.
[CUSTOMER][NEUTRAL] OK, alright, I just wanted to see if you guys would take care. I don't know. I, I, I think there's an issue with billing in this area, um, because these were, these were from my understanding this was the.
[CUSTOMER][NEUTRAL] Um, you know, the co-pays, but, you know, what do I know? I don't, I don't do billing, so.
[CUSTOMER][POSITIVE] All right then I guess I'll take care of it. Thank you.
[AGENT][POSITIVE] OK, there's anything else I can help with, thanks for contacting API.