AccountId: 011433970860
ContactId: 1dd5dc69-29cd-477d-aaf7-5f0adc9a9a25
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 999239 ms
Total Talk Time (AGENT): 443497 ms
Total Talk Time (CUSTOMER): 356058 ms
Interruptions: 7
Overall Sentiment: AGENT=0.4, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/28/1dd5dc69-29cd-477d-aaf7-5f0adc9a9a25_20250228T18:41_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] a
[CUSTOMER][NEUTRAL] Hi, I um, I have some questions on a claim that I submitted for my husband.
[AGENT][NEUTRAL] OK. You're the primary policy holder and you're checking claim status for your spouse, is that correct?
[CUSTOMER][NEUTRAL] No, my, my husband is, I'm, um, submitted the information on, on for him.
[AGENT][NEUTRAL] OK. Yes, ma'am. I can try and help you with this. Who am I speaking with, please?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] I'm so sorry, Ms. [PII]. OK, thank you. And what is a good callback number for you, please?
[CUSTOMER][NEUTRAL] Uh huh.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] Thank you and the policy number please Ms [PII].
[CUSTOMER][NEUTRAL] So it is um.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Not the group number the other number.
[AGENT][NEUTRAL] Uh-huh. Right.
[CUSTOMER][NEUTRAL] Um, like.
[CUSTOMER][NEUTRAL] 01 I mean I'm sorry yeah 0185063.
[CUSTOMER][NEUTRAL] 4.
[CUSTOMER][NEUTRAL] 0185 0634
[AGENT][NEUTRAL] OK, thank you. So give me a moment, Miss [PII]. No, ma'am, not yet.
[CUSTOMER][NEUTRAL] You want a claim number or?
[AGENT][NEUTRAL] So give me just a moment to get all the information pulled up.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Just
[AGENT][NEUTRAL] OK, Miss. [PII], any information that I do provide for you will be a verification of benefits and not a guarantee of payment. I will need to verify several things with you first for security. So first off, if you could please verify your husband's name and date of birth and then your date of birth.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, it's [PII] and his date of birth is [PII].
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] And then my date of birth is [PII].
[AGENT][NEUTRAL] Thank you. And your home mailing address, please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you. The phone number that we would have on, well, the file, the one that we have on file is your number.
[AGENT][NEUTRAL] That you gave me, OK? And then the last thing is the email address that we have on file. This does also appear to be yours.
[CUSTOMER][NEUTRAL] Mm, yes, yes.
[CUSTOMER][NEUTRAL] [PII]. I mean [PII] um.
[CUSTOMER][NEUTRAL] [PII]. I'm getting the other emails mixed up.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] Uh, that's OK. All right. And do you have, you said you had a claim number specifically, Ms. [PII]?
[CUSTOMER][NEUTRAL] Um, yes, because I got a response back and I don't understand it. It's 356-689-8.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So yes ma'am, I can say that that claim was denied.
[AGENT][NEUTRAL] Uh, give me just one moment.
[AGENT][NEUTRAL] OK, so the remarks on here.
[AGENT][NEUTRAL] State receipt of your claim is acknowledged, however, in order to provide further consideration of this loss under this policy, we will need supporting documentation to evidence the accident or sickness. Supporting documentation may include but is not limited to itemized bills with the diagnosis codes, super bills, office notes, hospital admission and discharge summaries, and diagnostic testing results. You said that you did, it appears that there was not a diagnosis code.
[CUSTOMER][NEUTRAL] Which I think that.
[CUSTOMER][NEUTRAL] Well, he went to the emergency room for a dog bite. So, um, I don't know if that said anywhere on there or the papers that I sent.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] Uh, let me see if I can.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] Exam X-ray exam of hand is on the explanation of benefit.
[AGENT][NEUTRAL] Right, but that's not the diagnosis. We, yes, the, that's, we're needing the why he was there.
[CUSTOMER][NEGATIVE] Well, how do I get that because I, I, it acts like they I didn't send the the bill with the codes and I did.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I called them and I said I, I need for insurance that you know exactly that and this is what they sent.
[CUSTOMER][NEUTRAL] So, it's got codes on it.
[CUSTOMER][NEUTRAL] Do you show the paperwork that I sent in?
[AGENT][NEUTRAL] I'm trying, um, that is loading. Mhm. Yes, that is, that is loading.
[CUSTOMER][NEGATIVE] I'm confused.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So there's the claim form.
[AGENT][NEUTRAL] That's the Aetna EOB which would not have that information.
[AGENT][NEUTRAL] That
[AGENT][NEUTRAL] we do have to have the explanation of benefits, but it does not have the diagnosis.
[AGENT][NEUTRAL] Codes on it.
[AGENT][NEUTRAL] Yes and say this is only saying what he had done with the, the exam codes, I mean, the X-ray.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] OK. I haven't come across anything with the diagnosis on it yet. Give me just a moment.
[CUSTOMER][NEUTRAL] First
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] So, yes, ma'am. Um, this information, I've looked at each of the pages and it does not include a diagnosis code. It does have the procedure codes.
[AGENT][NEUTRAL] But it does not have the Y.
[CUSTOMER][NEUTRAL] So who do I get that from?
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] You would, yes.
[CUSTOMER][NEUTRAL] The medical center he went to?
[AGENT][NEUTRAL] Yes, ma'am. Uh-huh. You would contact them and.
[CUSTOMER][NEGATIVE] And that's all we're lacking because it makes it sound like there's a bunch of stuff we're lacking.
[CUSTOMER][NEUTRAL] That this letter.
[AGENT][NEUTRAL] According to what I can see, yes, ma'am. I can see that.
[AGENT][NEUTRAL] I can see all of those remarks.
[AGENT][NEUTRAL] Um
[CUSTOMER][NEUTRAL] I just when I call them I just wanna know what.
[CUSTOMER][NEUTRAL] I'm, I'm asking them for.
[AGENT][NEUTRAL] Yes ma'am, so I will be happy. I can connect you with one of our examiners who reviews this type of claim to verify that, but it appears that it is going to be the diagnosis code that we are needing.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] But um again I will connect you over. I will let them know that you're it's been verified so that we do not have to, you know, you will not have to do that again. Yeah, so is there anything else that I could help you with before I do that?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Go through all that, OK, uh huh OK.
[CUSTOMER][NEUTRAL] No.
[AGENT][POSITIVE] OK, well then, thank you again for calling APL and I hope that you have a very nice weekend, Miss [PII].
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] You're welcome. So one moment, please.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Referring.
[CUSTOMER][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII] speaking. How can I help you?
[AGENT][POSITIVE] Hey [PII], it's [PII]. Happy Friday.
[CUSTOMER][POSITIVE] Hey [PII] thank you how are you?
[AGENT][NEGATIVE] Uh, I'm OK. I'm pretty shut down. My sinuses, I've been having a terrible time with them for a minute now, and I feel them shutting down on me right now. Usually, it's about the time I get off. It gets really bad, but it's, for some reason today, it's starting early. OK. So I have um an insured on the line who's calling regarding a claim that we reviewed on her husband, which she submitted all the information for.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] And she's wanting to verify exactly what we're needing. It appears it's only the diagnosis code. I've gone over the remarks on the claim with her, [PII]. But there's a this is one of those that has like a lot of verbiage. I really don't ever see this one too often, to be honest with you, but it's on policy number 1850634.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The claim is for part one [PII] and it's claim number 356-6898.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, I'm pulling that up now.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And like I said,
[AGENT][NEUTRAL] I've gone over the remarks with her, which she already had because she, all the information in the system is hers, the email, the phone number, all of that.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I'm gonna pull up that claim.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I guess you can pull it up while I'm in it because I pulled up the documents to try to.
[CUSTOMER][NEUTRAL] So we just switched that's a new remark code it is a little bit lengthy but basically it's telling them we need that uh.
[AGENT][NEUTRAL] Um.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] We need the diagnosis, procedure code, um.
[AGENT][NEUTRAL] A lot of stuff.
[AGENT][NEGATIVE] But there's, see, I don't, I don't really like that code then because procedure codes are included, so that doesn't tell them really what we need because she's, we've got that other stuff.
[AGENT][NEGATIVE] You see, I don't like it. That's gonna be even, that's gonna be so confusing to them.
[CUSTOMER][NEUTRAL] Oh wait, that's a med link.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So she's just wanting to like make sure she knows what she's supposed to be asking for when she contacts.
[AGENT][NEUTRAL] The facility again.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] I'm not understanding much either, to be honest, so let me try to dig in a little further. I don't see any additional notes.
[AGENT][NEUTRAL] Yes
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Hm.
[AGENT][NEUTRAL] I did not either, but I can, you know, see the procedure case. I see the EOB.
[CUSTOMER][NEUTRAL] Usually I mean.
[CUSTOMER][NEUTRAL] It's Medin too, so I'm not sure where they were going with this one.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And if you don't know Roxy, you know I don't know.
[AGENT][NEUTRAL] I was gonna say that I might.
[AGENT][NEGATIVE] Oh no, I'm going to be suffocating.
[CUSTOMER][NEUTRAL] Unless they didn't, it almost what they looked at the UBO4 so uh.
[CUSTOMER][NEUTRAL] Let me see if I can look at the diagnosis. OK. Well, I'm not sure what to tell her. I think maybe I might have to.
[AGENT][NEUTRAL] Is there a diagnosis code on there? I didn't see that. I mean.
[CUSTOMER][NEUTRAL] There is a diagnosis code that's saying that it's an open bite, so I'm not sure.
[AGENT][NEUTRAL] She did say it was for a dog bite. She did say that, but.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] I don't know.
[CUSTOMER][NEUTRAL] I might have to reach out to the adjuster and ask exactly what sort of supporting documentation or I mean unless they're asking.
[CUSTOMER][NEUTRAL] For admit and discharge summary, I think that that's what I'm gonna tell her because that's the only thing that we don't have um and it's possible like for [PII] I wanna say that.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, I just, I've never even seen this. I don't know that on a meddling policy, to be honest with you.
[CUSTOMER][NEUTRAL] Yeah, that's, I think it's because it's an accident, but that's gonna be, it's an accident diagnosis. So I think that that could be the only thing, but um
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Like I said, it looks to me like that's the only thing that we don't do not have, and that apparently that's what they're looking for is supporting documentation, so that would be like I said either the admit discharge summary or um possibly the ER you know documentation notes from the physician.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So and it's the who am I speaking with?
[AGENT][NEUTRAL] Uh,
[AGENT][NEUTRAL] Part two, [PII], the wife.
[CUSTOMER][NEUTRAL] Or 2.
[CUSTOMER][NEUTRAL] OK and you said everything was verified correct?
[AGENT][NEUTRAL] Yeah, uh-huh. And the phone number that's in Lion is actually her number and the email address on file is her email.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] And that is also the number she's calling from.
[CUSTOMER][NEUTRAL] Yeah, I see that.
[CUSTOMER][NEUTRAL] [PII]. OK, you can go ahead and transfer her over.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, well, well, will you let me know on this one since I haven't come across one like this before?
[CUSTOMER][NEUTRAL] In the meantime I'm
[CUSTOMER][NEUTRAL] Yeah, like I said that's, that's my guess is they're looking for that supporting documentation, but sure, um, I can give you a follow up and let you know uh once I.
[AGENT][NEUTRAL] I don't
[AGENT][NEUTRAL] Yeah, just, I mean you can just send me a message. I mean teams or something just kind of hey you know.
[AGENT][NEUTRAL] Whatever
[CUSTOMER][NEUTRAL] I'm pulling up their policy now because like I said, I believe it does have something to do with it being an accident diagnosis.
[CUSTOMER][NEUTRAL] Uh, I don't really do [PII], so.
[AGENT][NEUTRAL] Uh.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] I might
[AGENT][NEUTRAL] I see.
[AGENT][POSITIVE] She's really nice. She's just, like I said, she's just kinda wanting to before she starts trying to chase the stuff down again because she thought she had everything.
[AGENT][NEUTRAL] Um,
[AGENT][NEGATIVE] And when I read that and then looked at the documentation, I was not clear.
[AGENT][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK, now I'm looking at the policy, so just making sure that I'm.
[CUSTOMER][POSITIVE] At least where I'm going with it.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][POSITIVE] It's about the best I could do.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] But you can go ahead and transfer her over and um.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Well, I continue to review this.
[AGENT][NEUTRAL] OK, you sure?
[AGENT][NEUTRAL] You ready?
[CUSTOMER][NEUTRAL] Yeah I think so.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] As as ready as you're gonna get.
[CUSTOMER][NEUTRAL] Right, because like I said that's the only thing that I can um come up with is that's what they're looking for is that um supporting documentation.
[AGENT][NEGATIVE] Yeah, I'm saying I'm not getting anything like.
[AGENT][NEUTRAL] I mean, I'm looking, I've looked at the policy as well, and I mean it's not clear to me.
[CUSTOMER][NEUTRAL] And we do have.
[CUSTOMER][NEUTRAL] Yeah, we do have her here. OK, I was just looking at the EOB now to make sure.
[AGENT][NEUTRAL] Yeah, and that's yeah that's fine.
[CUSTOMER][NEUTRAL] But I wasn't seeing any anything else.
[AGENT][POSITIVE] OK, well thank you so much for this I appreciate you.
[CUSTOMER][POSITIVE] No problem, you're welcome.
[AGENT][POSITIVE] And if I don't talk to you again, have a great weekend.
[CUSTOMER][POSITIVE] You too, hope you feel better.
[AGENT][POSITIVE] Thanks, [PII]. I mean, this is happening like fast and it with Fast and Fury, I may not be able to survive all afternoon, my goodness. OK. Well, thank you so much. And so here comes um Miss [PII] then.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][POSITIVE] OK. Thank you, [PII]. Bye.
[AGENT][POSITIVE] All right, bye bye. Thank you. Bye.