AccountId: 011433970860
ContactId: 03d46706-8a0d-49b9-aa8d-0259cc5d6c94
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 933520 ms
Total Talk Time (AGENT): 390563 ms
Total Talk Time (CUSTOMER): 367204 ms
Interruptions: 2
Overall Sentiment: AGENT=0.4, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/24/03d46706-8a0d-49b9-aa8d-0259cc5d6c94_20250124T19:22_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], um, my name is [PII], and I had filed a claim and I then was asked to submit additional documentation, um, and it was, uh, you know, a detailed, um, you know, invoice for my doctor, um, for December services, and it looks like, um.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] The information had several dates of service on there and then I received information back from APL saying that none of those services were covered but I don't think they were looking at the correct services on the date because it says [PII] and the day I went to the emergency room was [PII].
[CUSTOMER][NEUTRAL] Are you able to help me just clarify because the the um detailed invoice from the from the doctor I'm sorry, had a lot of information on it so I just wanna make sure that it was looking at the right data service.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK. Well, I can definitely check on the claim for you and make sure the correct date of service is being reviewed. Um, [PII], may I have a good contact number just in case we're disconnected and then your policy number?
[CUSTOMER][NEUTRAL] Absolutely, um, my number is [PII].
[CUSTOMER][NEUTRAL] And my policy number is 02551253.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And can you verify your date of birth, your mailing and email address on file?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yes, it's [PII]. My email address is [PII].
[CUSTOMER][NEUTRAL] And my address is [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. So would this be the last or the most recent two claims? I see them here. OK.
[CUSTOMER][NEUTRAL] Yeah, so, yeah, I think there's actually 3 claim numbers that coincide. So the, the date that I went to the emergency room was [PII].
[CUSTOMER][NEUTRAL] But then like the doctor made me come back like a couple days later to do a follow up. So like when I, I submitted the documentation and I submitted the EOB, which the EOB has like me and my kids on it, so it was kind of a lot. So I called and they said, can you get the detailed invoice from your doctor? And I did that and they submitted that one, but then when I look at the most recent claim, it says the date of service was [PII], which was my follow up doctor's appointment.
[CUSTOMER][NEUTRAL] And said that none of those services were covered, um, and I that wasn't um what I was looking for my coverage to cover. I was looking for the emergency room which has like a $6000 bill on it um, does that make sense? I'm, I'm sorry if I'm all over the board. OK.
[AGENT][NEUTRAL] It does.
[AGENT][NEUTRAL] No, no, it's OK. So, looking at the claims, um, I'm just going through them to get the denial reason and then where we are now. Hold on one second, so there goes the [PII], I mean the [PII], [PII]. Hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Cool.
[AGENT][NEUTRAL] So for the
[AGENT][NEUTRAL] So for [PII], let me see how I can break this down. OK, I'll do it like this.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] So we have claim number 3546333, which was the original claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Then we have 354-913-7.
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] Which includes, well, it's the same dates, but it's different providers. So this is all [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEGATIVE] Now, these claims were denied.
[AGENT][NEUTRAL] Or this claim was denied because the service is not covered when performed in a doctor's office or clinic. So it's not what's being done, it's the place of service. So your policy covers the secondary policy now, not your major. Your secondary policy covers like in office or I'm sorry, in hospital, so like if you're admitted, um, that coverage in hospital and then it goes into outpatient, so like the emergency room, urgent care.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So I was in the emergency room.
[CUSTOMER][NEUTRAL] So I was in the emergency room on Ja I mean sorry, on [PII].
[CUSTOMER][NEUTRAL] I, the, the bill, it says emergency room, and it's like an $8000 bill, and I had to get a CT scan, which is in, in the emergency room, which I believe is covered. So the CT scan and then the emergency visit. Yeah.
[AGENT][NEUTRAL] Hold on.
[AGENT][NEUTRAL] So, what I'm trying to, so what I was going to get to, the there's a facility charge for the emergency room and then you have like actual charges for the emerg what was done in the emergency room. So for the actual facility charge, that one and I'm on claim 354-9137.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The actual facility charge is still being denied requesting the diagnosis code. So let me look and see, so you have sent that in.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Yes, and that claim number is 35, well, um, yes, I did send that in um hold on it's um uh it's attached um to claim number 3553561.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so let me go to that one and look at the charges.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] And so that's where it gets confusing.
[CUSTOMER][NEGATIVE] Because it says that the, you know, I don't know, it's very confusing for me and I'm, I'm not that great with this stuff, sorry.
[AGENT][NEUTRAL] So,
[AGENT][NEUTRAL] It's OK. So I'll, I can.
[AGENT][NEUTRAL] Well, there's a few things.
[AGENT][NEUTRAL] Of the, of the claim of the claims that were denied or the reasons that they were denied, some of them were like.
[AGENT][NEUTRAL] There's multiple denial reasons, but for what you have resubmitted,
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] I'm gonna reach out to.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Let me reach out to claims and get an examiner on the line so that they can look into the how it was examined further just so that we can see like for this last claim that came in when you resubmitted those documents that they know is for the other claim because on this document on this claim, like the the one that ends in 53561.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] That's where the documents are, but the charges are on the previous claim. So, so I'm gonna make reach out to them and see um if they if, yeah, if they put that all together.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] So you're here? OK, good.
[CUSTOMER][NEUTRAL] Thank you. Yeah, so I think what happened is because my doctor, they, so when I did call last time, they said we need your diagnosis from your doctor of why you were admitted to the emergency room so we can cover the emergency room. Does that make sense? Like, so I had to go because the doctor, I went into a doctor's appointment for a stomach ache. I was like, hey, I'm not feeling well. And she's.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Like, I'm calling the emergency room, you go right now. Like, I, there was, there was like, it was really scary for me. I don't know. I'm, I get scared when doctors. I was like, what? So she, they, they told me that they needed the doctor of why she made me go to the emergency room to cover, you know, the emergency room CT scan and that kind of thing. And I was like, great.
[AGENT][NEUTRAL] Right.
[CUSTOMER][POSITIVE] But it doesn't, so I don't, I think that that's where I need help and I'm, I again, I appreciate all your help because it's confusing for me but I wanna make sure that.
[CUSTOMER][NEUTRAL] Um, you know, that it wasn't, it wasn't coming from the emergency room, the diagnosis code, it came from my doctor. So, please let me know what you need from me. I, I will, I will do whatever it takes.
[AGENT][POSITIVE] So, I think the easiest thing to do.
[AGENT][NEUTRAL] Because I mean we can get claims if you want, but I mean the easiest thing is to just go through these lines, majority of the lines have been, when I say lines, I'm speaking of like the different dates of service and the different coding.
[AGENT][NEUTRAL] So, on
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Because the majority of these lines outside of the emergency room are being denied because of the place of service. So like 355-3561, that's that's.
[AGENT][NEUTRAL] The denial code except for
[AGENT][NEUTRAL] There's one on here.
[AGENT][NEUTRAL] What is this? DH.
[AGENT][NEUTRAL] Policy provides no benefits for treatment of conditions other than, OK, this is not covered by the policy. So this [PII].
[AGENT][NEUTRAL] I'll let them know that the documents are on here, but these, uh, the lines on this claim, it's because of the place of service and then that one code is, is not covered by the policy.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. And, and the only thing I really care about is honestly the emergency rooms. It, it's so expensive and uh insurance only covered so much. So, um, and I, I, I thought that.
[CUSTOMER][NEUTRAL] My service, my, my policy with you guys did cover emergency room and like the CT scan, which is the most expensive. The blood work and like the stay in the facility, like I'll, I get that, but if, if there's any way to cover the emergency room, I'm not saying cover everything. Obviously, my policy is only like $2000.
[AGENT][NEUTRAL] The facility charge, OK.
[CUSTOMER][NEUTRAL] Yeah, I, I just, I'm just looking for that one specific line item and I think that that's what's happening is there's so much data on everything I'm giving that it's hard to match it up with the previous data with what I really need coverage for.
[AGENT][POSITIVE] OK, well, I can definitely.
[CUSTOMER][NEUTRAL] I had to go to the doctor a lot.
[AGENT][NEUTRAL] Well, I can definitely reach out to um reach out to claims and see if they can explain this further.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] I would appreciate that thank you so much.
[AGENT][NEUTRAL] You're very welcome. Hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] What?
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] What have you seen this?
[AGENT][NEUTRAL] OK, I'm on a call.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] He can sing girls, he sing.
[AGENT][NEUTRAL] Oh
[AGENT][NEGATIVE] Medli, where are, where is everything? Oh Lord, I almost hung up.
[CUSTOMER][NEUTRAL] Ferring.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] This is [PII]. How may I help you?
[AGENT][NEUTRAL] Hi [PII], this is [PII] on the care team. How are you?
[CUSTOMER][POSITIVE] I'm pretty good. How are you?
[AGENT][POSITIVE] I'm doing OK. I have an insured. We're going over claim status. I went through everything with her.
[AGENT][NEUTRAL] Um, she still wants to speak with someone though. Um, can I give you the, the, you want the policy number, like the claim number?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Oh, the policy number is great.
[AGENT][NEUTRAL] OK, it's 255-1253.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So, basically, of the 3 claims that we've processed for her.
[AGENT][NEUTRAL] This last claim here, 53561 has the documents from the things that were denied on the other claims.
[AGENT][NEUTRAL] So she's, I explained everything to her, the denial reasons was needed, but she's saying I already submitted all of that on [PII]. They just have to look through those documents like the diagnosis code is being asked for an emergency room visit, um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] And the detailed explanation of benefits.
[CUSTOMER][NEUTRAL] OK, uh, because I think I'm looking at the wrong one. The one that I, I'm sorry, I, I must have pulled up the wrong one, the one that I had, uh, it looks OK. So it's the one ending in uh 6333, is that what she's asking? Because the others, um, and they, they look like they're just.
[AGENT][NEUTRAL] Well, so the 6333 was the original claim, but she's saying she, she submitted the documents for the
[CUSTOMER][NEUTRAL] Oh, I see.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Basically, she submitted all the documents from everything that we asked for in this last claim she sent.
[CUSTOMER][NEUTRAL] This last claim, the one that was denied uh as office visits and stuff like that, right? OK.
[AGENT][NEUTRAL] Right, mhm.
[CUSTOMER][NEUTRAL] OK. OK. All right. OK.
[AGENT][NEUTRAL] Because at first I was like, well, it's the place of service and then she's like, but I sent the the documents in this last claim. I said, oh, you sent the, so then everything connected and I'm like,
[CUSTOMER][NEUTRAL] Diagnosis codes and things, OK.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] OK, yeah, sure. I can, um, I'll go ahead and look at it. Yes, yeah, I can help her. Thanks.
[AGENT][NEUTRAL] OK, thank you, [PII]. Hold on one moment, OK?
[CUSTOMER][NEUTRAL] Uh OK. Uh-huh, thanks.
[AGENT][NEUTRAL] Hello [PII].
[CUSTOMER][NEUTRAL] Yes, hello.
[AGENT][POSITIVE] Thank you so much for holding. I apologize for that wait. I have [PII] on the line and she'll be assisting you further, OK?
[CUSTOMER][POSITIVE] Thank you so much for your help I appreciate it.
[AGENT][POSITIVE] You're very welcome and thanks for calling APL.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, [PII]