AccountId: 011433970860
ContactId: 0188eaea-c68b-43e6-89a6-81bf630dc52e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 994609 ms
Total Talk Time (AGENT): 410907 ms
Total Talk Time (CUSTOMER): 234435 ms
Interruptions: 0
Overall Sentiment: AGENT=0.2, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/08/0188eaea-c68b-43e6-89a6-81bf630dc52e_20250408T20:16_UTC.wav
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[AGENT][POSITIVE] Thanks for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hello [PII] um.
[AGENT][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] I was calling to um just to see uh check the status of my claim.
[AGENT][NEUTRAL] OK, uh, do you have your policy number?
[CUSTOMER][NEUTRAL] Just wanna make sure I turned everything in properly and say what?
[AGENT][NEUTRAL] Um, do you have your policy number?
[CUSTOMER][NEUTRAL] Um, I don't, not on me. I can look it up.
[AGENT][NEUTRAL] Uh, do you have your social?
[CUSTOMER][NEUTRAL] I do.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It's [PII]
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And can I get your name and a good callback number?
[CUSTOMER][NEUTRAL] My name is [PII].
[CUSTOMER][NEUTRAL] And my phone number is [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK. Last name was [PII], is that right?
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] Is that [PII]?
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] OK, and then [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, give me just a moment.
[AGENT][NEGATIVE] Sorry, my system is running just a bit slow, um.
[CUSTOMER][NEUTRAL] No, you're fine.
[AGENT][NEUTRAL] Not, not pulling up your name or that uh social. Do you have a group number by chance?
[CUSTOMER][NEUTRAL] A group number?
[CUSTOMER][NEUTRAL] Um, I could pull it up.
[AGENT][NEUTRAL] In the street for you.
[AGENT][NEUTRAL] OK, is this through your employer?
[AGENT][NEUTRAL] This policy?
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] Yes, uh, yes, it's through my employer.
[AGENT][NEUTRAL] Oh, OK, what's the name of your employer?
[CUSTOMER][NEUTRAL] Falcon Fire Department.
[CUSTOMER][NEUTRAL] Uh and Fire Protection District.
[AGENT][NEUTRAL] Is that [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] 24
[AGENT][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] OK, I've located it. Um, is this for let's see what.
[AGENT][NEUTRAL] Is this for your accident policy or?
[CUSTOMER][NEUTRAL] Yes, accident.
[AGENT][POSITIVE] Yeah, OK, perfect.
[CUSTOMER][NEUTRAL] You could just
[AGENT][NEUTRAL] OK, just need to verify a few pieces of information. What's your birth date?
[CUSTOMER][NEUTRAL] My birth date is [PII].
[AGENT][NEUTRAL] And your address?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And the city?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, and then lastly just your email address.
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][POSITIVE] OK, thank you so much.
[AGENT][NEUTRAL] OK and you said you filed a claim recently, is that right?
[CUSTOMER][NEUTRAL] Yes, 2 claims actually. I just wanna make sure.
[CUSTOMER][POSITIVE] Filled everything out properly and.
[CUSTOMER][POSITIVE] You have all the information you need.
[AGENT][NEUTRAL] OK, let me pull up what we received.
[AGENT][NEUTRAL] OK, um.
[AGENT][NEUTRAL] OK, I've got some documents from your MyChart.
[AGENT][NEUTRAL] Let me see what we've got.
[AGENT][NEUTRAL] Um, OK.
[AGENT][NEUTRAL] Sorry, I'm reading through these, making sure we've got what we need.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I see all the records from the my chart which.
[AGENT][NEUTRAL] I'm trying to find did they provide you like a claim?
[AGENT][NEUTRAL] That shows diagnosis and procedure codes.
[AGENT][NEUTRAL] And then like the bill charges.
[CUSTOMER][NEUTRAL] And who provide that?
[AGENT][NEUTRAL] The hospital where you had surgery?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I thought I provided that. I thought I sent that in.
[AGENT][NEUTRAL] OK, let me look. I, we've got 5 documents here, so let me.
[AGENT][NEUTRAL] Let me look through these, hold on one moment.
[CUSTOMER][NEGATIVE] Yeah, but I just haven't received anything from uh.
[AGENT][NEUTRAL] Did you
[CUSTOMER][NEUTRAL] APL, so I was like, oh I hope I did everything right.
[AGENT][NEUTRAL] Yeah, I'm looking through. Did you upload it 5 times? Is that right? Does that sound right?
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] 5 documents.
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] No, I, so I have 11 claim for a hernia.
[CUSTOMER][NEUTRAL] Um, that I had surgery on, and then there's another claim for a torn quadriceps tear.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Two different claims
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And I thought I submit a paperwork for.
[CUSTOMER][NEUTRAL] Both. I've done physical therapy on both.
[CUSTOMER][NEGATIVE] I just don't know what to submit. I, I tried my best here and they were both done on the job too, so they were through workers' comp, so it's been very difficult getting the information and I thought.
[CUSTOMER][POSITIVE] I finally got it and submitted it.
[CUSTOMER][NEUTRAL] For both claims, the paperwork.
[AGENT][NEUTRAL] OK, I'm looking, so the first, the first document that I saw, it looks like it's uh documentation from like your My chart, and it, that's for the hernia, but
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] What we, what we have to see and, and I'm, I'm only on the 2nd document you submitted, so I'm trying to see what all we received, um.
[AGENT][NEUTRAL] So did work, did they deny this?
[CUSTOMER][NEUTRAL] Deny what? Do I do.
[AGENT][NEUTRAL] The charges?
[AGENT][NEUTRAL] Typically if it if you hurt yourself on OK so they did pay for the charges?
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Yeah, workers' comp pay for everything.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, let's see.
[AGENT][NEUTRAL] A lot of the times that's an it's an exclusion under the policy, so I'm trying to, um, I wanna make sure that I tell you the right thing, so.
[AGENT][NEUTRAL] Let me see.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Did you see the accidental claim form filled out?
[AGENT][NEUTRAL] I
[AGENT][NEUTRAL] I do. I see I see documents that you've submitted, um, let me check and see where the claim form is.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] OK, yes, I see the claim form that you've submitted.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Here's your claim form. Sorry, I'm just getting this all pulled up, so.
[CUSTOMER][NEUTRAL] Yeah, I guess I
[CUSTOMER][POSITIVE] Thank you for your help.
[AGENT][POSITIVE] Yeah, absolutely.
[AGENT][NEUTRAL] OK. So we've got documents regarding the tear and then documents regarding the hernia. I see the claim form that you've uploaded.
[AGENT][NEUTRAL] Looks like um you uploaded two claim forms about that.
[AGENT][NEUTRAL] Um, let's see.
[AGENT][NEUTRAL] What I was gonna check is on your policy.
[AGENT][NEUTRAL] Sometimes claims it's an exclusion so it won't pay for anything if if you if this was a workers' compensation claim so I I'm gonna double check that.
[AGENT][NEUTRAL] And this is not, not a guarantee of payment, it's just a basic outline of your policy.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me check and see if that's an exclusion.
[AGENT][NEUTRAL] OK, I don't see that that is an exclusion, um.
[AGENT][NEUTRAL] Just making sure.
[CUSTOMER][NEUTRAL] Oh, that, that what is an exclusion.
[AGENT][NEUTRAL] That
[AGENT][NEGATIVE] Do an injury due to that's on the job would not be covered.
[AGENT][NEUTRAL] That's what I was checking on.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Oh, so is it, it is not covered?
[AGENT][NEUTRAL] No, I don't, I don't show it should be covered um as long as we have all of the correct information, so just making sure.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, let's see. OK, so based on what I can see of what's been uploaded, so we, we do need very specific information. We need to know the exact procedures, um, that were performed, like the there's codes. There's codes that are, that are required for the surgeries, so they're called CPT codes, and then we need to know the exact diagnosis. I do see some of your documents have a diagnosis on them.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] But looking through these, I'm not seeing like a breakdown of
[AGENT][NEUTRAL] You know, this surgery code for the hernia repair was $5000. I'm just giving you an example. Um, so that's kind of what I'm looking through these. I'm not seeing that.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So do you, you need billing information?
[AGENT][NEUTRAL] Yes, because we need to know the procedures that happened and then we need to know what your diagnosis is to determine that this was due to an accident.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So do you see CPC codes?
[AGENT][NEUTRAL] I'm looking through everything and I'm not seeing any CPT codes but I.
[AGENT][NEUTRAL] There's several pages here, so I'm trying to make sure. So right now it's.
[CUSTOMER][NEUTRAL] But that that's
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] I was gonna say cause I, I did see some diagnosis diagnosis tos on there.
[AGENT][NEUTRAL] I did too.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I saw 2 specifically.
[CUSTOMER][NEUTRAL] And I mean, I'm, I'm sorry, I've never done, haven't done this before, so I'm, I'm.
[CUSTOMER][NEUTRAL] I'm not clear as to what you're looking for and I realize y'all know what y'all are looking for.
[CUSTOMER][NEUTRAL] But uh I don't know.
[CUSTOMER][NEUTRAL] What it looks like, you know what I mean? I, I don't.
[AGENT][NEUTRAL] No, I get you. Yeah, sure. The easiest thing is, so when you went and had surgery, were these both outpatient? Is that right? You didn't stay overnight?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] That's correct. And, and I did not have surgery on the tendon, just, just on the hernia.
[AGENT][NEUTRAL] OK, just on the hernia and then physical therapy with the tendon.
[CUSTOMER][NEUTRAL] Um, yeah, I have physical therapy on both.
[AGENT][NEUTRAL] Oh, OK, OK, OK, so usually what we're looking for that has all of this information is gonna be the claims from the providers, um, so there's a couple of things we can do right now. We've got all the information that you submitted it's in line for processing, OK, so it should be processed within the next 5 working days or so. Our claims department will look through all of the documentation that we've received.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then determine if we are missing anything, what exactly is missing.
[AGENT][NEUTRAL] Um, so we can wait for the claims to go through processing, um, and then we can again they'll look at links through every page that you sent and make sure and see do we have everything we need. If we don't, we will send you a detailed explanation of exactly what we need.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, um.
[CUSTOMER][NEUTRAL] So you said process it 55 business day within 5 business days. Is that 5 business days after the day it was submitted or is that from today?
[AGENT][NEUTRAL] That's from today, so we received it on [PII], and our current turnaround time is about 7 to 10 business days from that date. So that's how I was just quoting should be around 5 business days, so.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and second question.
[CUSTOMER][NEUTRAL] Where do I get communication as far as what you know if you need other documentation right, should I just, I just waiting? Do I get an email? Do I have to go back into my account?
[CUSTOMER][NEUTRAL] Because like when I, when I do the um.
[CUSTOMER][NEUTRAL] Not the accidental, but the wellness.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Uh, side of it, I get a bunch of letters in the mail, um, but nothing ever says that, you know, sometimes it just gets denied and sometimes it gets
[CUSTOMER][NEUTRAL] Push through and then you know I don't really, it's not clear on if I need to turn in other information or not. So do I get, is there any kind of um correspondence or any kind of communication?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, so
[CUSTOMER][NEUTRAL] Or do I just sit back and wait?
[AGENT][NEUTRAL] No, we'll send you by mail. We will send you your explanation of benefits, but that will also be available on the portal. So I would wait, wait about 5 working days or so, check on the portal and see if that's uploaded yet, but we will send that by regular mail as well. So it'll have a line by line information of what exactly we need.
[AGENT][NEUTRAL] If we need anything.
[CUSTOMER][NEUTRAL] If you need anything, and it'll also say if I've been denied.
[AGENT][POSITIVE] Correct. Correct.
[CUSTOMER][NEUTRAL] Right? OK.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, alright, I'll just, uh, continue to wait then.
[AGENT][NEUTRAL] OK, is there anything else I can help with today?
[CUSTOMER][POSITIVE] No, that's it. Thank you.
[AGENT][POSITIVE] OK. Thank you for calling APL. I hope you have a good day.
[CUSTOMER][NEUTRAL] Alright you too bye bye.
[AGENT][NEUTRAL] I