AccountId: 011433970860
ContactId: 06267879-decb-4a8a-b967-5855bb693253
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1115500 ms
Total Talk Time (AGENT): 294132 ms
Total Talk Time (CUSTOMER): 254873 ms
Interruptions: 0
Overall Sentiment: AGENT=1.3, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/24/06267879-decb-4a8a-b967-5855bb693253_20250324T16:17_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] from the care team. I have a member on the line who is questioning um a denial for a claim.
[CUSTOMER][NEUTRAL] And I'm just now realizing it's for her spouse, so let me see if she.
[CUSTOMER][NEUTRAL] Can we tell them the details for specific denial reasons for the spouse?
[CUSTOMER][NEUTRAL] Because it's a ICC client.
[AGENT][NEUTRAL] Is the spouse, are they, is the person on the phone the primary?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, so what's the policy number?
[CUSTOMER][NEUTRAL] Uh, policy number is 592.
[CUSTOMER][NEUTRAL] 141
[AGENT][NEUTRAL] OK, so the person on the phone is [PII].
[CUSTOMER][NEUTRAL] Yes, that's correct, and then it's I've got the claim number for her spouse.
[AGENT][NEUTRAL] OK, what's the claim number?
[CUSTOMER][NEUTRAL] 1404898
[AGENT][NEUTRAL] OK, the claim back from [PII]?
[CUSTOMER][NEUTRAL] Yeah, [PII], yeah.
[AGENT][NEUTRAL] Is that correct?
[CUSTOMER][NEUTRAL] Yeah, I, I asked a couple of times because
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] I'm like, goodness gracious, this is very old.
[CUSTOMER][NEGATIVE] But she was kind of getting into why was this denied I've paid into it all this time I'm not understanding why what why wasn't more paid on the claim, um.
[CUSTOMER][NEUTRAL] That's why I thought I might send her over to you to kind of talk more at length and detail about what.
[CUSTOMER][NEUTRAL] What we were needing if she could provide it.
[AGENT][NEUTRAL] OK, give me just a second to pull up the claim.
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] I verified her too by the way sorry, I didn't mention that.
[AGENT][NEUTRAL] OK, give me just a moment just taking a look so I.
[AGENT][NEUTRAL] Know what to tell her.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] OK, yes, I'm ready for it.
[CUSTOMER][POSITIVE] OK, here you go thank you.
[AGENT][POSITIVE] Thank you.
[AGENT][POSITIVE] Thank you for holding this is [PII].
[CUSTOMER][NEUTRAL] Um, [PII], this is [PII]. I am calling about um some intensive care, um, benefits that I.
[CUSTOMER][NEUTRAL] Applied for for my husband.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEGATIVE] And they were denied because it said uh it was supposed to be the highest level of intensive care. Well, it was, it was.
[CUSTOMER][NEGATIVE] In intensive care, he was in intensive care. The codes might not have been right.
[CUSTOMER][NEUTRAL] Um, but I called someone.
[CUSTOMER][NEUTRAL] And they tell me, um,
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] That those codes were.
[CUSTOMER][NEUTRAL] Supposed to be for intensive care.
[CUSTOMER][NEUTRAL] And um,
[CUSTOMER][NEUTRAL] I don't know. I want to resubmit the claims. I don't know if I need to get a lawyer or if the doctor needs to verify these, the hospital and she said, uh,
[CUSTOMER][NEUTRAL] So we had to go back in the records and on some of the claims that said surgical services. Well, he was not, he didn't have surgery, he was in intensive care.
[CUSTOMER][NEUTRAL] And I don't know if that's what that meant.
[CUSTOMER][NEUTRAL] Because that's what it said a lot of, you know, I've got the, the bills and that's what it's coded. It says surgical services.
[CUSTOMER][NEUTRAL] And he was in intensive care, and I don't know if I need
[CUSTOMER][NEUTRAL] To get the doctor to do, but I want to resubmit these claims because it was definitely intensive care because he almost died.
[AGENT][POSITIVE] OK, sure, I'll take a look at that for you.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Sure, bear with me just a moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, so yes, I'm looking in your policy certificate and does verify that for the intensive care policy that we would need um room charges for the intensive care or coronary care unit.
[AGENT][NEUTRAL] Um, so let me, I'm gonna look back in the claim to see if we have charges, um.
[AGENT][NEUTRAL] For that particular room.
[CUSTOMER][NEUTRAL] Well, can you look at the code? Maybe the the code is correct, but maybe the explan or description is wrong because it was definitely intensive care.
[CUSTOMER][NEUTRAL] At um
[CUSTOMER][NEUTRAL] Two different hospitals.
[CUSTOMER][NEUTRAL] She said the code was correct. I yeah I talked to.
[AGENT][NEUTRAL] OK, let's
[AGENT][NEUTRAL] OK, so I'm looking at the facility bill from Saint Francis Medical Center.
[AGENT][NEUTRAL] And I don't see that there are codes next to the room charges. It just has the data service, a charge which it may have like a charging code, but that would just be specific to that hospital. We wouldn't know what that, I mean, it's just a set of numbers um we wouldn't know what that means in in accordance to that facility.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Um, it does have a description name which it just says RM Critical Care Services, so it does not specify intensive care or coronary care, and then it has the amount that was billed next to it.
[AGENT][NEUTRAL] Um, so it doesn't have like a revenue code next to it that would be like a universal code.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] So I don't know if that's what she was referring to.
[CUSTOMER][NEUTRAL] Now, what do I need to do?
[AGENT][NEUTRAL] Um, let me just
[CUSTOMER][NEUTRAL] But what do I need to do?
[AGENT][NEUTRAL] Uh, sure. I'm just gonna look through here a couple more pages just to see if there's any other, um, charges that might verify if it's intensive care or coronary care.
[CUSTOMER][NEUTRAL] Because this was
[AGENT][NEUTRAL] Um, so I'm seeing more it as critical care service.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, and some places it says surgical.
[CUSTOMER][NEUTRAL] Services, but it wasn't surgery, it was in intensive care.
[AGENT][NEUTRAL] OK, let's see.
[CUSTOMER][NEUTRAL] I've been paying on this policy for a very long time.
[AGENT][NEUTRAL] Yes ma'am, so I can take a look here and see exactly what we'll need um to go ahead and finish complete the processing of this claim for you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Excuse me.
[CUSTOMER][NEUTRAL] I see.
[AGENT][NEGATIVE] No thank you.
[AGENT][NEUTRAL] OK, yes, bear with me just a moment. I'm just kind of looking through just to be sure that.
[CUSTOMER][NEUTRAL] That's fine.
[AGENT][NEUTRAL] I'm not missing anything.
[AGENT][NEUTRAL] Mm OK.
[AGENT][NEUTRAL] OK, I do see where some of it says surgical services.
[AGENT][NEUTRAL] Um, yes, so, unfortunately, that just doesn't give us the information that we need to verify what type of level of care they were receiving, um, cause normally, you know, with facility bills, it's either gonna have just a room, like a regular hospital room charge, or it's gonna have, you know, intensive care or coronary care, and sometimes they even call it um a step up care or telementary, um, which would be a step up from a regular room, so.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] I mean, what can I do?
[AGENT][NEUTRAL] With how
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] It was an intensive.
[AGENT][NEUTRAL] Uh, so what, what you can do is go back to um that, the, the facility, the Saint Francis Medical Center and say that you need an itemized bill that confirms um intensive care charges.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] That you that you need to verify that you were billed for intensive care unit and if for some reason that they're still not able to provide any revenue codes or billing, um, you can also just request like any um medical records that verify the intensive care room um that, that the level of care that he was receiving was the highest level at that hospital facility.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And we can review that and, and see if that's able to confirm that, you know, that he was in the, that he was being billed for the intensive care unit for those dates of service.
[CUSTOMER][NEUTRAL] OK. All right.
[CUSTOMER][NEUTRAL] To see if they can give me an itemized bill first and then uh
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] If they can't go the medical records.
[AGENT][NEUTRAL] Yes, so see if they can get like an itemized bill showing the room charges for the intensive care unit.
[AGENT][NEUTRAL] Um, and if for some reason, they're not able to, because this has been a few years, so that's, that's my only concern if they're not able to go back that far, um, that if they have some sort of medical records of where it shows that he was uh, admit in the intensive care unit in for those days of service.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] I will do my best.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] All right, when I, if
[CUSTOMER][NEUTRAL] I can get those that I just resubmit.
[CUSTOMER][NEUTRAL] With that information, resubmit the claim or what?
[AGENT][NEUTRAL] Yes, ma'am, um, yes, and if you can just attention it to the policy number for your intensive care, um, that's 528453.
[AGENT][NEUTRAL] And then we'll make sure that that it's reviewed under your intensive care policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] And just mail it in.
[AGENT][NEUTRAL] Yes ma'am, you can either mail it or you can fax it or if you also have access to our online service center you can also submit your claims online.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] We don't have internet, so I would have to go somewhere to send it, but
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] OK, I guess that answers all my questions.
[AGENT][NEUTRAL] Uh, sure, Ms. [PII], was there anything else I could do to help you today?
[CUSTOMER][NEUTRAL] I don't think so.
[AGENT][POSITIVE] OK, thanks for calling APL. Oh, I'm sorry?
[CUSTOMER][NEUTRAL] I just get the
[CUSTOMER][NEUTRAL] I said I just need to get this taken care of.
[AGENT][POSITIVE] Oh yes ma'am, no I understand and if you have any other questions, please feel free to give us a call, OK?
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] Thank you. You have a good day. Thanks for calling APL.