AccountId: 011433970860
ContactId: 1c0c7da9-37a5-4002-af98-1b6a7a8051c5
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 845750 ms
Total Talk Time (AGENT): 461550 ms
Total Talk Time (CUSTOMER): 261328 ms
Interruptions: 4
Overall Sentiment: AGENT=0.1, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/25/1c0c7da9-37a5-4002-af98-1b6a7a8051c5_20250625T15:45_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How may I help you today?
[CUSTOMER][NEUTRAL] Hi, good morning. I'm calling to follow up on a claim. I sent you guys an email 8 days ago and I haven't heard from you.
[AGENT][NEUTRAL] OK, go ahead and give me your name and your policy number, please.
[CUSTOMER][NEUTRAL] So my name is [PII].
[CUSTOMER][NEUTRAL] Let me get the card with the policy.
[AGENT][NEUTRAL] Alrighty, it's gonna be that certificate number.
[CUSTOMER][NEUTRAL] Uh, I'm sorry, it's gonna be what?
[AGENT][NEUTRAL] Your certificate number on your ID card.
[CUSTOMER][NEUTRAL] So it's uh 0259.
[CUSTOMER][NEUTRAL] 3894.
[AGENT][NEUTRAL] Alright, [PII], thank you for that information. Now while I'm pulling this up, go ahead and give me a good return telephone call number, please.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] All righty, [PII], thank you for all that information. Now, go ahead and verify your date of birth, address, and.
[AGENT][NEUTRAL] Email address right quick.
[CUSTOMER][NEUTRAL] Date of birth date is [PII]. I'm sorry, what else do you need?
[AGENT][NEUTRAL] Your address?
[CUSTOMER][NEUTRAL] Uh, [PII], uh, that's in, I'm sorry, [PII]. That's in [PII]. Zip code is [PII].
[AGENT][NEUTRAL] All right, go ahead and verify your email address for me right quick. Let's make sure we have that correct.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Yes, ma'am. All that information is correct and thank you so much. All right, [PII], you said you sent a claim in-house and you want to check status. What is the date of service?
[CUSTOMER][NEGATIVE] Yeah, so I sent on 2 coins at first and you guys send me a check for the reimbursement. Now I send 3 new claims and I haven't heard from you.
[AGENT][NEUTRAL] Well, what's those dates of service so I could check them? Yes, ma'am, just go ahead and give me those dates of service.
[CUSTOMER][NEUTRAL] I just wanna follow up.
[CUSTOMER][NEUTRAL] I'm sorry?
[AGENT][NEUTRAL] Yeah, those dates of service so I can check to see if we have them.
[CUSTOMER][NEUTRAL] OK, so it's uh [PII], [PII] [PII], [PII].
[AGENT][NEUTRAL] Alrighty, let me key those in. Let's see, I'm gonna do 221, 2025 1st. It looks like we do have that claim in-house.
[AGENT][NEUTRAL] Let's see, it's for some lab charges looks like.
[AGENT][NEUTRAL] Yeah, it looks like we've made a payment. Let me go see when we paid that, so bear with me just a moment.
[AGENT][NEUTRAL] Let's see.
[CUSTOMER][POSITIVE] Alrighty.
[AGENT][NEUTRAL] 2 of 4.
[AGENT][NEUTRAL] Yeah, it looks like you're gonna be getting a check for that. It printed on.
[AGENT][NEGATIVE] 69, no this printed on 5959 um 0 you've already gotten this check 253-53 for 221 is already been paid so you send it in again and it was denied a duplicate.
[AGENT][NEUTRAL] So let me go and check 2:20.
[AGENT][NEUTRAL] 4, let's make sure about that one. It's like you're gonna be getting a check on it too. Let me get it pulled up. Let's see 3 this is your latest 10, it was just put in, uh, this morning, so the check is not even printed yet for this one. So the one for 224 looks like.
[AGENT][NEUTRAL] And for dates 225 was just put in this morning so that check will not print to overnight tonight so I'm not sure what the amount is gonna be until it prints tonight but you might can check back in the morning when it prints tonight and we can tell you what that check's gonna be for just.
[CUSTOMER][NEUTRAL] I'm sorry. Let's just go again. Uh, the call is breaking up a little. So, the claim for [PII], the, the one that's the ultrasound for $159. So what's the status on that?
[AGENT][POSITIVE] Oh, I'm sorry.
[AGENT][NEUTRAL] Uh, the 221 claims had already been paid. Which, uh, how much was that bill for you said?
[CUSTOMER][NEUTRAL] So, on [PII], I had two different things done.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] One was a blood test with Quest, which you guys already sent me the check for $50.
[AGENT][NEUTRAL] Yeah, I see that. Mhm.
[CUSTOMER][POSITIVE] So that's done, that's good.
[CUSTOMER][NEUTRAL] But now the other exam I did on, on [PII] was an ultrasound.
[CUSTOMER][NEUTRAL] And that I already paid $159. So I haven't heard from you guys for that one, that test.
[AGENT][NEGATIVE] Yeah, I do. Yup, I do see that test and it's being denied routine, not covered because according to the diagnosis that was submitted, yeah, that, that's not, that's not a, an injury or illness. It is an encounter for an investigating test, so that is not gonna be covered here. That's gonna be considered routine.
[CUSTOMER][NEUTRAL] No, but that was not for routine. That's because I'm having, um, they thought I might have some issues.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] And that's why my doctor asked me to just.
[AGENT][NEUTRAL] OK. Well, uh, what I would advise because the diagnosis that we have, it's not gonna be payable, but you might want to check back with them.
[AGENT][NEUTRAL] That provider that did the ultrasound and have him resubmit, I'll give you a different diagnosis.
[AGENT][NEUTRAL] Code that is, that, that's a not routine.
[CUSTOMER][NEUTRAL] Um.
[AGENT][NEUTRAL] And you can resubmit that with that information in writing from your, from your physician.
[CUSTOMER][NEUTRAL] So let me get it again.
[CUSTOMER][NEUTRAL] What is the code?
[AGENT][NEUTRAL] Uh, I can't tell you what the code is, but the code that that was submitted is routine, which is not going to be covered.
[AGENT][NEUTRAL] But you can call this this providers your doctor's office and tell them that you need um a medical diagnosis for that and he can send it to you but it has to be in writing from that physician and you can resubmit your claim when you receive that information from your physician's office.
[CUSTOMER][NEUTRAL] So what exactly do you need? You need a letter from them?
[AGENT][NEUTRAL] Uh, any, any documentation from them that would tell the medical diagnosis on that, that ultrasound that was done.
[AGENT][NEUTRAL] Tell me you need an ICD 10.
[CUSTOMER][NEUTRAL] I'm sorry, yeah.
[AGENT][NEUTRAL] Code.
[CUSTOMER][NEUTRAL] I'm sorry, let's do it again. You need a document from them?
[AGENT][NEUTRAL] Yes, ma'am. It has to be from the doctor's office.
[CUSTOMER][NEUTRAL] OK, what is the document?
[AGENT][NEUTRAL] Uh, we need an ICD 10.
[AGENT][NEUTRAL] Diagnosis code.
[CUSTOMER][NEUTRAL] I as in Igloo. C as in Charlie. D as in David 10.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, and that's the letter, right?
[AGENT][NEUTRAL] Yeah, uh, either a letter or any documentation that that doctor can give you.
[CUSTOMER][NEUTRAL] OK. All right, I'm gonna ask my doctor.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Um, OK. So the [PII], um, that is the highest, um, it's an exam, um, for 276. What is the status on that, please?
[AGENT][NEUTRAL] Yeah, that claim was just processed this morning, so that check will not print until tonight, so I don't know the total exact check. Well, I'll take that back. Hang on, I can add them up. Hang on just a second.
[AGENT][NEUTRAL] Right
[CUSTOMER][POSITIVE] Alrighty, thank you.
[AGENT][NEUTRAL] Um, yes, ma'am. See if I can give you that check. Uh, let's see.
[AGENT][NEUTRAL] Yes, ma'am. It's gonna be for 27,670. Like I said, it will not print till tonight, will not go out to the following day.
[CUSTOMER][POSITIVE] OK, perfect. And then the [PII], the sonogram.
[AGENT][NEUTRAL] Yeah, right.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] For 224. And what is the status on that, please?
[AGENT][NEUTRAL] How much is it for? 224?
[CUSTOMER][NEUTRAL] And 294 49 cents.
[AGENT][NEUTRAL] For 225 [PII] data service?
[CUSTOMER][NEUTRAL] Yeah, [PII].
[AGENT][NEUTRAL] Yeah, I don't see anything for that amount. I do see several claims. Let's see what this code now, that's not it.
[AGENT][NEUTRAL] I have something for $506. Let's see what that's for.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] 768506.
[CUSTOMER][NEUTRAL] 500? Let me see.
[AGENT][NEUTRAL] $6. That's for an echo exam of the uterus.
[CUSTOMER][NEUTRAL] That will be one of them.
[AGENT][NEGATIVE] I don't see anything for the amount, yeah, I don't see anything for the amount that you're giving.
[AGENT][NEUTRAL] at all, but let's see.
[CUSTOMER][NEUTRAL] But do you see for
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Yes, ma'am. I'm on [PII].
[AGENT][NEUTRAL] Yeah, that's the date that I have pulled up looking at it, and I'm trying to see.
[AGENT][NEGATIVE] Hm, I don't see anything for the amount that you're giving me here at all.
[CUSTOMER][NEUTRAL] I was there paying the other one combined.
[AGENT][NEUTRAL] Yes, they are combined. Yes, ma'am. 24 and 25 are combined on your ELB, but it looks like we are asking for additional information from several of the charges that you submitted on [PII].
[AGENT][NEUTRAL] That we need uh documentation supporting uh the medical diagnosis from your physician's office as well.
[CUSTOMER][NEGATIVE] Like, I, I, you know, every time I call they said submitted the explanation of benefits. So I grabbed the explanation of benefits with Aetna and I uploading your system, and then they deny saying it's a duplicate. I don't even know how to deal with this.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Oh, you're doing it the correct way because we're, we are getting it.
[AGENT][NEUTRAL] But now when you submit these claims and um like I said, that the diagnosis, we consider routine is not gonna be covered.
[AGENT][NEUTRAL] So that's, that's why I was saying, you know, go ahead and, and resubmit those claims. I do see on 225 that you resubmitted some and those claims have been denied routine because of the diagnosis that was submitted on those bills are not gonna be covered here. So uh that's you're gonna be getting the COB that's gonna tell you exactly what you can get, which is the same that I told you on the other day.
[AGENT][NEUTRAL] Service that we need a medical diagnosis and medical documentation from your doctor's office.
[AGENT][NEUTRAL] Will your doctor's office file these claims for you?
[CUSTOMER][NEUTRAL] For the
[CUSTOMER][NEUTRAL] Yes, that's for [PII] exam that you need the documents.
[AGENT][NEUTRAL] Yes, ma'am. And, and 225, 20, yeah, 225 as well.
[CUSTOMER][NEUTRAL] OK, that
[CUSTOMER][NEUTRAL] But I think you just said the 225 they're reimbursing.
[AGENT][NEGATIVE] Yes, ma'am. It's not gonna reimburse because of the diagnosis that you resubmitted. It's not covered. It's, it's considered routine here.
[CUSTOMER][NEUTRAL] OK. I guess gonna post on the website or you're gonna send me a letter?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] You're gonna get this COB. Like I said, it printed, yeah, it's gonna print tonight, so you will receive this in the mail in a couple of days.
[CUSTOMER][NEUTRAL] I guess I'll just wait to understand how much I'm getting.
[AGENT][NEUTRAL] Yes, ma'am. I would, yeah, just, yeah, just wait.
[AGENT][NEUTRAL] We'll be till Monday or Tuesday and let all this information get to you so you can review it that way you'll kinda understand more about what I'm talking about.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All righty. OK. Thank you so much. Appreciate it.
[AGENT][NEUTRAL] All right. Well, you're welcome, [PII]. Now is that all I can help you with?
[CUSTOMER][POSITIVE] That's all. Thank you.
[AGENT][POSITIVE] OK. Well, yes, ma'am, [PII], and thanks for calling APO and you have a great rest of your day, OK?
[CUSTOMER][NEUTRAL] You too. Bye bye.
[AGENT][POSITIVE] Thank you, ma'am. Bye-bye.