AccountId: 011433970860
ContactId: 0f4a31a3-e2e4-4eac-82bf-bab061704a3e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 495350 ms
Total Talk Time (AGENT): 277318 ms
Total Talk Time (CUSTOMER): 226718 ms
Interruptions: 11
Overall Sentiment: AGENT=0.8, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/23/0f4a31a3-e2e4-4eac-82bf-bab061704a3e_20250423T21:52_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], how are you?
[AGENT][POSITIVE] Good, how are you?
[CUSTOMER][NEUTRAL] Uh, I'm here.
[CUSTOMER][NEGATIVE] Oh, I have a member on that. She's been crying, um, and I think, yeah, they're already closed meddling, oh no. I'm so confused, girl, it's the end of the day.
[AGENT][NEUTRAL] It's almost [PII], so what you doing?
[CUSTOMER][NEUTRAL] I know. Uh, has [PII] closed their too or no?
[AGENT][NEUTRAL] Um, there should be someone there, I think. Hang on, give me just a second.
[CUSTOMER][NEUTRAL] I have no idea.
[CUSTOMER][NEUTRAL] OK, OK, uh.
[AGENT][NEUTRAL] Uh, it looks like there's 3 people there, um, [PII] and [PII].
[AGENT][NEUTRAL] Are available.
[CUSTOMER][NEUTRAL] OK, let me call. OK, let me call [PII] because I think y'all don't handle [PII], right?
[AGENT][NEUTRAL] I mean, I can.
[CUSTOMER][NEUTRAL] You sure?
[AGENT][NEUTRAL] Yeah, yeah, what you got going on?
[CUSTOMER][NEUTRAL] OK, OK, OK, let me explain to you what happened. OK. So, policy number is 2336107. This is a Spanish call, so I'm not gonna transfer. I just need the information.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, OK, so she's, she has some claims that we paid and then she has some claims that we did not pay. Um, she said that she sent the same exact information, um, for this, for this claim, so she wanted to know why we didn't use the same information to pay her other claims. Um, so this is, um, basically what I got. Um, the date of service that we're looking into is [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Of 25.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Uh-huh, yeah.
[AGENT][NEUTRAL] OK, is that that DM 39?
[AGENT][NEUTRAL] Claim is it on part one or is it under a different part number?
[CUSTOMER][NEUTRAL] Mm, I'm, OK.
[CUSTOMER][NEUTRAL] I it's in part one. You got Florencia pulled up?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, so.
[AGENT][NEUTRAL] 4, OK, let me just get it pulled up, so I see one claim number that's not paid.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, all of the other ones have been paid.
[CUSTOMER][NEUTRAL] Yeah, so it's the one that is not paid, um.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] And this is not even, this is the 21.
[CUSTOMER][NEUTRAL] Give me just a second, I don't know.
[AGENT][NEUTRAL] Your phone.
[CUSTOMER][NEUTRAL] She just, I, I tried, but she just kept talking and I was trying to look into all the paperwork and it was like, OK, and then she keeps saying, go to this date, and you will see it's the same information and go to this date, and you will see the same information. So right now I'm just, OK, so [PII]. OK, so let me look at this. OK.
[AGENT][NEUTRAL] OK, so I see two lines for [PII].
[CUSTOMER][NEUTRAL] OK, you know what, it's not [PII], it's [PII]. I'm so sorry for that.
[AGENT][NEUTRAL] That's OK, so [PII] we denied as no diagnosis code was provided.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] So let me see if I can find that date and we'll definitely look at it because if that was an error, then we'll get that fixed.
[CUSTOMER][NEUTRAL] OK. So.
[CUSTOMER][NEUTRAL] Mhm. OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] OK. I got you. I got you. Deep breath, girl. Deep breath. OK. Yeah.
[CUSTOMER][POSITIVE] OK, thank you, thank you, thank you.
[AGENT][NEUTRAL] OK, so 3:21 urgent care visit.
[AGENT][NEUTRAL] Um, acute URI.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] We have a diagnosis.
[AGENT][NEUTRAL] For 321.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so 321 DX equals acute URI.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] Great process
[AGENT][NEUTRAL] OK, um, I'm going to let me see what the other denials are because I don't want her asking you another questions and then you don't know.
[CUSTOMER][NEUTRAL] Mm OK.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] The next, let's say 321.
[AGENT][NEUTRAL] Truthfully, I think.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] I think the examiner just got ahead of themselves because there's even education materials that reference an upper respiratory.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, so I think they just got ahead of themselves and not paying attention, yeah.
[CUSTOMER][NEUTRAL] Yeah, I saw that. Yeah. OK. OK. OK. I just wanna make sure. Yeah, I was just looking at, I said, well, it does say it, it's not a code, but it does say the diagnosis. That's why I said let me check and see if we can use that because it looks like that's what you, we have used in the past. Mhm.
[AGENT][NEUTRAL] Which is fine, we'll go ahead and look at that.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Yeah, it does say it.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Yes, so the only thing is, do we also have the EOB for this date?
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] Because with it being meddling we will need that so that's what I'm looking for of course there's 22 pages so.
[CUSTOMER][NEUTRAL] Mm. OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Oh.
[CUSTOMER][NEGATIVE] There's a lot of pages, she sent a lot of pages, that's the thing, that it's like all mixed up.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] She did. She sent all of her records.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah, and it's all mixed on different, different claims. So it's not just this one.
[AGENT][NEUTRAL] Oh gosh.
[CUSTOMER][NEUTRAL] Uh, yeah, that's why I'm like, oh, and I just, you know, when you have seen so many papers that you kind of get lost, you know what you're looking for, but you, you get lost.
[AGENT][NEUTRAL] Yes.
[AGENT][POSITIVE] Yes, for sure, OK.
[CUSTOMER][NEUTRAL] But yeah, I, I think this one is also under that 22 pages. I believe it's in page 18, if I'm not mistaken.
[AGENT][NEUTRAL] So,
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] OK, I do see an EOB 324 319.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] Um, 321 is on.
[AGENT][NEUTRAL] Page 19 urgent care for 321. She highlighted it.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So she knows that we have it we have two charges for the urgent care actually, so we have one for $693 and then we have one for $388.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It looks like there was a co-pay of 50.
[AGENT][NEUTRAL] For the, for one of them and then their everything else was.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, and it looks like, yeah.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So
[CUSTOMER][NEUTRAL] Yeah, she's looking for that copay. Mhm.
[AGENT][NEUTRAL] She's looking for the 50. OK, alright, so I am going to highlight this.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] What I will do is um.
[AGENT][NEUTRAL] I will send.
[AGENT][NEUTRAL] Uh, a request to have this reprocessed to the examiner.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And I would say, you know, ask her to give us some time. These we do ask just for your knowledge we do have in our emails to the examiners that they have 2 business days to complete.
[CUSTOMER][NEUTRAL] Mhm, yeah.
[AGENT][NEUTRAL] This um request. So, um,
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] You know, give us some, but that will definitely be considered. Is there anything else that she mentioned specifically before I send you back to her?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, no, it was just that day. She was just like, well, you have used this before. Why you cannot use this for this one as well. So yeah, that's, that's basically what's her question.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah
[AGENT][POSITIVE] Yeah, no, yeah, she's absolutely right. So, yep, I will, I'll make a note of this for the examiner and we'll get this taken care of. It probably, they're probably gone by now so um it'll be tomorrow, but it'll get handled.
[CUSTOMER][NEUTRAL] OK. Uh.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Let me answer.
[CUSTOMER][POSITIVE] It's fine. All right, thank you so much. You're a saver.
[AGENT][POSITIVE] You're so welcome. I got you, girl. I got you.
[CUSTOMER][POSITIVE] Thank you. You have a good afternoon, [PII]. Bye-bye.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] You too, bye bye.