AccountId: 011433970860
ContactId: 1a73455d-bf28-4dbb-9334-9cd13615fa92
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 671640 ms
Total Talk Time (AGENT): 403540 ms
Total Talk Time (CUSTOMER): 235450 ms
Interruptions: 4
Overall Sentiment: AGENT=0.6, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/25/1a73455d-bf28-4dbb-9334-9cd13615fa92_20250425T13:50_UTC.wav
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[AGENT][NEUTRAL] Contacting APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII]. What information do you need to look up my claim?
[AGENT][NEUTRAL] Uh, do you have your policy number there with you?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Hang on, let me see if I have it.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I was looking at a document.
[AGENT][NEUTRAL] Uh, would you tell me how to spell your last name?
[CUSTOMER][NEUTRAL] And the policy number.
[AGENT][NEUTRAL] Oh, uh-huh.
[CUSTOMER][NEUTRAL] 2573221
[AGENT][NEUTRAL] 221. Thank you. And if I could verify uh your um
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Date of birth and a phone number, please?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] Great. Thank you so much. Now, you said that uh there's a claim that we could look at. Uh, what is the date of service?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] Hang on.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] 216. OK.
[AGENT][NEUTRAL] OK, so let's see what we have here.
[CUSTOMER][NEUTRAL] I looked at the denial and it said that it was for an office visit. The explanation of benefits that I sent over had two different, um, two different line items. One was for the office visit with Doctor [PII], and then the other one was for the.
[CUSTOMER][NEUTRAL] Um, the MRI.
[CUSTOMER][NEUTRAL] At the MRI center and I provided a bill. It's the EOB had two different er had two different service dates on the same document.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Yes, um, so it looks like there's 2, uh-huh, please go ahead. I'm sorry.
[CUSTOMER][NEUTRAL] And I would
[CUSTOMER][NEUTRAL] And I'm not looking for the Hung Park MD office visit. I am looking for the reimbursement for the in center MRI facility for my gap claim.
[AGENT][NEUTRAL] Right, right, I see.
[CUSTOMER][NEUTRAL] And when I called for my benefits, it should, it was, it, it's in the documentation that I read.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Since it's a outpatient facility, but it's an MRI facility, it would have been covered.
[AGENT][NEUTRAL] It is. It certainly is. Um, so what we, uh-huh.
[CUSTOMER][NEUTRAL] OK, then why was it denied?
[AGENT][NEUTRAL] It's not denied, it's pended. So what we're looking at um.
[AGENT][NEUTRAL] Uh, [PII], is that, uh, we need a, uh, diagnosis code from the provider. Um, what in the diagnosis code is, uh, the reason that you had the MRI. So, um,
[AGENT][NEUTRAL] That should be listed on normally when you go to the doctor or you sometimes they will give you an itemized bill. It gives you a diagnosis like this is why, uh, this is why I went in on this day, um, uh, for, uh, you know, what is it back trouble.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] And what about the bill that I provided?
[AGENT][NEUTRAL] It didn't actually show that on there. Let me see if I can't pull it up again. um, let's see.
[AGENT][NEUTRAL] So, uh
[AGENT][NEUTRAL] Let's give me just a second here. I'm gonna.
[CUSTOMER][NEUTRAL] So what about the map notes from the
[AGENT][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] From the radiologist.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Right, that's what I'm looking at now, so I'm just gonna see if I can't pull that up really quickly.
[CUSTOMER][NEUTRAL] Do you have the I didn't send over the nap notes, but I can.
[AGENT][NEUTRAL] Well,
[AGENT][NEUTRAL] Yeah, we might need that. Um, I'm gonna look at what, what you did submit and so let's just see what we have here and then we can um we can kinda go from there. So, uh, let's see.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And I, and I understand that what we're looking at is in inland imaging, so that's what uh.
[CUSTOMER][POSITIVE] Correct. Correct.
[AGENT][POSITIVE] The data service 216, so let's see we have your EOB that's great.
[AGENT][POSITIVE] Always helpful.
[AGENT][NEUTRAL] And sometimes even on the EOB they've got the diagnosis code, but that's what I'm looking for now and I don't see it. So I'm, I'm just going through all the documents that we did get.
[AGENT][NEUTRAL] Now, the notes from the um from your provider will sometimes give a diagnosis that it will say, you know, that you had this procedure done for these issues, you know, that you, uh, and I'm just using this as an example, maybe back trouble, um, uh, sprained ankle, whatever, whatever it is.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] No, yeah, well then that makes you say.
[CUSTOMER][NEUTRAL] Yeah, the n notes do state that, but I didn't send the that notes, um, because I sent over the EOB and the bill, and when I spoke with another, um, uh, lady over there earlier in the week, she was like, well, that's what we need is the EOB and the bill and you know, the claim form.
[AGENT][POSITIVE] Absolutely.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, well, we know sometimes the the the diagnosis for uh code is on the bill. Now, I'm uh I'm not actually seeing the bill itself. All I'm seeing are the EOBs, but if you have the, uh, the notes from the provider that would, that, that may end up telling us what we're looking for. So what we're looking for is, is the, is the provider's diagnosis and it's, it's not, the claim isn't denied. What it is is it's just pending until we get the, those documents. And if you don't mind sending them to us.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] Uh, then we can, um, we can finish, um.
[CUSTOMER][NEUTRAL] No, I don't mind.
[AGENT][NEUTRAL] Because it looks like that's the only thing that we're looking at.
[CUSTOMER][NEUTRAL] Can you
[CUSTOMER][NEUTRAL] OK, the bill was attached to the back of the signed claim form. I uploaded two files. One file was the EOB and the other file was the APL claim form, and page number 3 was the actual bill.
[AGENT][NEUTRAL] Let me see what we've got here because I didn't actually I didn't see that but let me.
[AGENT][NEUTRAL] Let me pull it up one more time. Um.
[AGENT][NEUTRAL] And I'll just tell you what I, what I'm saying, uh.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] Excuse me just a moment. So what we have is um 14 pages. The first one is just an auto generated page that tells us that this is a claim uploaded by the policyholder dashboard. The second page is blank. Um, the third page is from Aetna, um, and it says explanation of benefits. This is not a bill. The fourth page says, uh, your claims up close, and then it begins with the one for 216.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Page 5, it says your benefit balances to date, um, which is really for you. Uh, number 6, this is the 6th page, your rights and protections against surprise medical bills, and that's just something that they put in with your EOBs every time. Uh, page 7, it says more information. Do you have questions for Aetna? Give us this information. Number 8 just says Washington State office, um.
[AGENT][NEUTRAL] Number 9
[AGENT][NEUTRAL] Uh, lists of different languages that you can get your EOB in, uh, like Tagalo or German or, um, yeah, and then 9 is a uh blank piece of paper. 11, um, is the Aetna, excuse me, I'm sorry, APL meddling claim form, and 12 is also part of that. So let's just keep going here. 13 is part of that. Now 14, um, what we have here is the imaging, uh, island imaging.
[CUSTOMER][NEUTRAL] But
[AGENT][MIXED] And on that, that is certainly the bill and that's always helpful, but there's nothing on here that gives us the diagnosis. Um.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So what it does is
[CUSTOMER][NEUTRAL] Got you. OK, so you have the bill.
[AGENT][NEUTRAL] Yeah. Yes, ma'am. I've got the bill and it, it tells us what.
[CUSTOMER][NEUTRAL] OK, so I'll go and I'll get the.
[CUSTOMER][NEUTRAL] I'll get everything from uh
[CUSTOMER][NEUTRAL] I'll get everything I can from the radiologist that would have some sort of diagnosis code, um, and I'll upload that. Do I need a separate claim form or like document, um, just upload it?
[AGENT][NEUTRAL] Yes.
[AGENT][NEGATIVE] Uh, no, no, no, no.
[AGENT][NEUTRAL] No, we, yes, please, if you'll just upload it then then we'll know what it's for and what we'll do is we will add it to the documentation that you've already uh submitted and then we'll just go from there.
[AGENT][NEUTRAL] So that is what we're looking for.
[CUSTOMER][NEUTRAL] OK. OK. Um,
[CUSTOMER][NEGATIVE] So it wasn't denied because it wasn't in an office visit. When I downloaded the documents that were on the website in the little um aligned explanation that talked about a doctor's visit in office and that's why I was a little dismayed because
[CUSTOMER][NEUTRAL] Uh, it has nothing to do with Doctor [PII]'s office visit. It was just on the same sheet that I sent the documents.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Right. Yeah, we have to, we have to look at everything and so, uh, but, uh, we do understand that the one that we're looking at or the one that we need to process is the imaging uh for that uh [PII]. That's, um, if we have the notes from that date or from that doctor letting us know what, what the imaging is for, and then you can just tell us, you can just, this is what the imaging was for for islands imaging.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And um we will uh just finish going at processing from there. Now, do we have any other uh claims we need to look at? Is there anything else that uh needs to be addressed or, or looked at? Any other claims or or questions about your policy that we need to uh address?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] No, it's just uh.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It's just this one claim that I'm submitting for for the MRI.
[AGENT][NEUTRAL] OK. OK. Well, we, we will be glad to, as I said, you don't need to give us another, um, uh, claim form. We will be able to take care of it with the claim form that we've got, and we will be, um, we'll be able to get that taken care of and, and, and, uh, usually it takes about 8 to 10 business days once we receive it, uh, if not less, so we will certainly be on the lookout for that.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And if you would
[CUSTOMER][POSITIVE] OK, I'll get it upload. I'll get it uploaded within the hour.
[AGENT][POSITIVE] OK, great. That's wonderful. OK, well, thank you very much for contacting me. Great. Well, that's, that's great and we'll be glad to look at it and, and um if uh if you have any questions that once you upload it, then please let us know.
[CUSTOMER][POSITIVE] It's easy for me to get, so.
[CUSTOMER][NEUTRAL] OK, and do I need to call and let anyone know or will it just sort of flag?
[AGENT][NEUTRAL] I
[AGENT][POSITIVE] It will go on the system and once you, once you submit it on our online service center, and that's the great thing about it is that we usually see it um pretty quickly um and then what we do is we have to process the claims as we get them, of course, but um, yeah, we, we see it pretty quickly, so there shouldn't be a problem there.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK. I'll go take care of that now.
[AGENT][POSITIVE] OK, well, thank you very much for contacting us and if you do have any other questions, just let us know.
[CUSTOMER][POSITIVE] Thank you. I appreciate the explanation and guiding me through it.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] OK, well, certainly, thank you very much for contacting APL. You have a very good.