AccountId: 011433970860
ContactId: 02f1f322-0151-4ff2-ace4-7fd694f72860
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1088000 ms
Total Talk Time (AGENT): 317249 ms
Total Talk Time (CUSTOMER): 286751 ms
Interruptions: 2
Overall Sentiment: AGENT=0.8, CUSTOMER=-0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/08/02f1f322-0151-4ff2-ace4-7fd694f72860_20250408T14:30_UTC.wav
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[AGENT][POSITIVE] Good morning. Thanks for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII] on the care team. I have a policy holder on the line. She wants to go over her claim denial and
[CUSTOMER][NEUTRAL] It it looks like it just processed today but she can see the EOB but I can't see it um so I was gonna see if you can help her, um, go through the claim denial because like I said I can't see the EOB so I and she's she wants to know exactly why things are denied.
[AGENT][NEUTRAL] OK, sure, do you have the policy number?
[CUSTOMER][NEUTRAL] Yes, it's um hold on just a second and I've verified her information. Um, policy number is 02597363.
[CUSTOMER][NEUTRAL] And I've got [PII] on the phone.
[AGENT][NEUTRAL] OK, and do you have a callback number?
[CUSTOMER][NEUTRAL] Callback number is [PII].
[AGENT][POSITIVE] OK, thank you. Give me just a second here.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, and what was the claim number that she or I guess one that was just processed today?
[CUSTOMER][NEUTRAL] Yeah, 358-612-3.
[AGENT][POSITIVE] OK, alright, I'm ready for it, thank you.
[CUSTOMER][POSITIVE] OK, thank you so much.
[CUSTOMER][NEUTRAL] Hello?
[AGENT][POSITIVE] OK thank you for holding this is [PII].
[CUSTOMER][NEGATIVE] Hi [PII], um, they transferred me to you because I'm not understanding why my claim was denied.
[CUSTOMER][NEUTRAL] I've never done an inpatient one with you guys either so I don't know.
[CUSTOMER][NEUTRAL] I submitted the same
[CUSTOMER][NEGATIVE] Thing that I submitted for my outpatient, but she's saying that it's missing something.
[AGENT][NEUTRAL] Uh, sure, Ms. [PII], I can take a quick look at that for you. Uh, bear with me just a moment, and you're referring to the claim that was just processed today, correct?
[CUSTOMER][NEUTRAL] Yes
[AGENT][NEUTRAL] OK, and you had a question regarding um the denial, is that right?
[CUSTOMER][NEUTRAL] Yes
[AGENT][NEUTRAL] OK, sure, bear with me just a moment, I'll just take a look at that claim for you, OK?
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] Like this has been really hard.
[AGENT][NEUTRAL] I'm trying to understand I'm sorry about that. Let me just take a quick look and we can see what what we need to be able to go ahead and finish processing this claim for you, OK.
[AGENT][NEUTRAL] Um, do you mind if I put you on hold for just a quick moment?
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] OK, I'm so sorry about that, Ms. [PII]. Are you still there?
[CUSTOMER][NEUTRAL] Yeah, I'm here.
[AGENT][NEUTRAL] OK. So yes, I am, I'm looking through your claim and so it does look like um for the benefits under your policy, it does cover for um.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] So for some of the charges, it does suggest that um you know, well, the, the benefits are payable only if your medical, major medical insurance provides your benefits. And so if on the EOB if it was, you know, initially denied, but if they do provide benefits later, um, you could please, you could also provide those EOBs and then we can re-review for some of those charges, um, so it does look like that some of the charges.
[CUSTOMER][NEGATIVE] But the ones that it says that were some of the charges were denied, but I didn't get charged for them.
[AGENT][NEUTRAL] Right, so for the one.
[CUSTOMER][NEUTRAL] Like, um
[AGENT][NEUTRAL] OK. Did you have one in particular you were looking at?
[CUSTOMER][NEGATIVE] Like they were explaining it to me because I had to I had to call them because I didn't understand it.
[CUSTOMER][NEUTRAL] Um, so it's like for um.
[CUSTOMER][NEUTRAL] Like I'm trying to remember everything that they told me so.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Like it said that.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEGATIVE] That one of them was it says it was denied like for $65.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] For thyroxine or something like that which they said it was not needed for the clinical situation as far as that they're concerned, but.
[CUSTOMER][NEUTRAL] They didn't charge me for that.
[AGENT][NEUTRAL] OK, so which which procedure code are you referring to on the claim and then I can take a look at the specific.
[CUSTOMER][NEUTRAL] OK, what, um, OK, so for example, what is the claim what code am I looking for?
[AGENT][NEUTRAL] One that you're referring to.
[AGENT][NEUTRAL] The procedure codes, so on your claim it will go by the the procedure codes on the EOB, um, for example, like.
[CUSTOMER][NEUTRAL] OK, so on my is that like the 36561?
[AGENT][NEUTRAL] Yes. Mhm.
[CUSTOMER][NEGATIVE] OK, so that one says that it was denied. INSJ tunneled CTRAD was subsequent portage 5 years. I had to have a meta port put in for chemo.
[CUSTOMER][NEUTRAL] So I don't know what the the claim number says 3 or the whatever code is 36561 and it says that um an assistant surgeon is not warranted with this procedure.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right, and so
[CUSTOMER][NEGATIVE] is why they denied that particular number.
[CUSTOMER][NEUTRAL] But they didn't deny the whole thing.
[AGENT][NEUTRAL] Right, just that procedure code. And so, so for that code, it looks like, you know, that wasn't covered by that was denied and so for your policy, you know, when it was reviewed and processed, um, you know, the benefits are only reimbursable if you're.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Major medical insurance provides benefits. And so that's what the the code that we use that if this claim, if that particular code is later paid by your major medical to send that explanation of benefits showing that they were paid and we can re-review for that procedure code.
[AGENT][NEUTRAL] For that 36561.
[CUSTOMER][NEUTRAL] OK, but what about?
[CUSTOMER][NEUTRAL] Yeah, but there's over I paid out I used all of my income tax to pay this, and there's oh there's $4,651.98 and there was another $300 it was almost, it was like $5000 5,0071 dollars or something that I had to pay for this bill, and they were approved and they did pay out the health plan paid $17,000 towards it and I had to pay $4000.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] $691 or $51.
[AGENT][NEUTRAL] So for the, the rest of the codes, um, so like for example like for example, the 326-66 and the 32674, um, what we're requesting is that we need to be able to, we need the diagnosis codes. Those codes weren't provided on this EOB um and so what, what you can provide that has a diagnosis code that confirms, you know, what the, what you were being treated for.
[AGENT][NEUTRAL] It's like an itemized facility bill from the facility. They usually have the diagnosis codes, um, any office notes or like a hospital admission or discharge summary. And so anything that has your diagnosis codes for the, for these dates of service, then we can re-review and be able to process out the rest of the claim that it is payable.
[AGENT][NEUTRAL] So that's that's, that's what it's being requested.
[CUSTOMER][NEUTRAL] OK, so.
[CUSTOMER][NEUTRAL] It states on there I had to have a metaphor put in and it states I had a wedge resection on my lung because they had to take out a tumor.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And you need something saying,
[AGENT][NEUTRAL] Yeah, so the procedure codes.
[AGENT][NEUTRAL] What your diagnosis is, your diagnosis codes.
[CUSTOMER][NEUTRAL] OK, I'm looking to see if I have that in.
[CUSTOMER][NEUTRAL] Here
[CUSTOMER][NEUTRAL] So like the test results?
[AGENT][NEUTRAL] Um, if it has the, the diagnosis codes on them, then yes, that, that can be, um, we can use that as well.
[CUSTOMER][NEUTRAL] I don't know where to look for these diagnosis codes. I don't know what you mean.
[AGENT][NEUTRAL] Um, so, like towards the top, like if like your diagnosis or whatever like condition you're diagnosed with, there should be like a code next to it. Um, and it's gonna kind of look like
[CUSTOMER][NEUTRAL] Um
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Let me get you an example.
[AGENT][NEUTRAL] Like it'll be like a letter in some numbers like for an example like C 50.
[AGENT][NEUTRAL] Would be a diagnose code, um.
[AGENT][NEUTRAL] Like it normally be like a uh a number and then like like two like a letter and then two numbers behind it.
[CUSTOMER][NEUTRAL] OK, hold on.
[AGENT][NEUTRAL] And it's, and it's just a code that, that tells us, you know, give a description of your diagnosis.
[AGENT][NEUTRAL] Like whether it's like an illness or an accident.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Yeah, they they usually will have a code.
[CUSTOMER][NEUTRAL] OK, this is my MRI of the brain.
[CUSTOMER][NEUTRAL] That's not it.
[CUSTOMER][NEUTRAL] There's no codes on that.
[CUSTOMER][NEUTRAL] those are dot.
[CUSTOMER][NEUTRAL] Document
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Hang on, I'm trying to find something.
[CUSTOMER][NEUTRAL] That has these codes there's notes.
[AGENT][NEUTRAL] Sure you're fine.
[CUSTOMER][NEUTRAL] And everything else and
[CUSTOMER][NEUTRAL] None of them have like they all say the diagnosis, but they don't have a code.
[AGENT][NEUTRAL] Mm, yeah, so normally I mean it can be on um like a super bill uh office notes or any itemized facility bills, um.
[AGENT][NEUTRAL] Like, or diagnostic testing results, though, those usually um
[AGENT][NEUTRAL] have some sort of like a code, a diagnosis code on them.
[AGENT][POSITIVE] I mean, you're free to send us whatever additional information.
[CUSTOMER][NEGATIVE] Yeah, that's what I'm looking at results notes. I don't wanna keep sending stuff just for it to keep getting denied.
[AGENT][NEUTRAL] Sure, or you can.
[CUSTOMER][NEUTRAL] Like I need to get it taken care of ASAP.
[AGENT][NEUTRAL] Request it from your doctor's office as well. If, if what you have doesn't have any codes on them. Um, you can also just request a bill with the um diagnosis codes as well.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] All right, if I can't find anything I will um call them and request it.
[AGENT][NEUTRAL] Sure, Ms. [PII], anything else I could do to help you today?
[CUSTOMER][NEUTRAL] And then just.
[CUSTOMER][NEUTRAL] Do I just upload it and it goes back like I don't have to upload the EOB again?
[AGENT][NEUTRAL] Right, no, we already have the EOB on file. You would just upload it and when you do, it will say a new claim, but it will just come in and we'll be able to match it with what you already have so you don't have to submit documents more than once.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Sure, and please let us know if you have any other questions, OK?
[CUSTOMER][POSITIVE] All right thank you.
[AGENT][POSITIVE] Sure, thanks for calling AP I hope you have a good day.
[CUSTOMER][NEUTRAL] You too bye bye.