AccountId: 011433970860
ContactId: 1ea29f03-871c-4816-b9e3-1c8bf7ed636c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 947919 ms
Total Talk Time (AGENT): 508231 ms
Total Talk Time (CUSTOMER): 388053 ms
Interruptions: 6
Overall Sentiment: AGENT=0.7, CUSTOMER=0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/28/1ea29f03-871c-4816-b9e3-1c8bf7ed636c_20250228T18:50_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII] speaking. How can I help you?
[CUSTOMER][POSITIVE] Hey, [PII]. It's [PII]. Happy Friday.
[AGENT][POSITIVE] Hey [PII] thank you how are you?
[CUSTOMER][NEGATIVE] Uh, I'm OK. I'm pretty shut down. My sinuses I've been having a terrible time with him 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 starting early. OK, so I have um an insured on the line who was calling regarding a claim that we reviewed on her husband which she submitted all the information for.
[AGENT][NEUTRAL] Oh.
[CUSTOMER][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.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The claim is for part one [PII] and it's claim number 356-6898.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I'm pulling that up now.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And like I said,
[CUSTOMER][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.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] I'm gonna pull up that claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I guess you can pull it up while I'm in it because I pulled up the documents to try to.
[AGENT][NEUTRAL] So we just switched that's a new remark code it's a little bit lengthy but basically it's telling them we need that uh.
[CUSTOMER][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] We need the diagnosis, procedure code, um.
[CUSTOMER][NEUTRAL] A lot of stuff.
[CUSTOMER][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.
[CUSTOMER][NEGATIVE] You see, I don't like it. Mm mm. That's gonna be even, that's gonna be so confusing to them.
[AGENT][NEUTRAL] Oh wait, that's a med link.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So she's just wanting to like make sure she knows what she's supposed to be asking for when she contacts.
[CUSTOMER][NEUTRAL] The facility again.
[AGENT][NEUTRAL] Hm.
[AGENT][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.
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] Mmm.
[AGENT][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] I did not either, but I can, you know, see the procedure case. I see the EOB.
[AGENT][NEUTRAL] Usually I mean it's med link too so I'm not sure where they were going with this one.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] And if you don't know Roxy, you know I don't know.
[CUSTOMER][NEUTRAL] I'm even gonna say that I might.
[CUSTOMER][NEGATIVE] Oh no, I'm going to be suffocating in that.
[AGENT][NEUTRAL] Unless they didn't, it almost, what they looked at the UBO4, so, uh.
[AGENT][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.
[CUSTOMER][NEUTRAL] Is there a diagnosis code on there? I didn't see that. I mean.
[AGENT][NEUTRAL] There is a diagnosis code that's saying that it's an open bite. So I'm not sure.
[CUSTOMER][NEUTRAL] She did say it was for a dog bite. She did say that, but
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh.
[AGENT][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.
[AGENT][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.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, I just, I've never even seen this. I don't know that on a meddling policy, to be honest with you.
[AGENT][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
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK.
[AGENT][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.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So, and it's the, who am I speaking with?
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Part two, [PII], the wife.
[AGENT][POSITIVE] Got you.
[AGENT][NEUTRAL] OK, and you said everything was verified, correct?
[CUSTOMER][NEUTRAL] Yeah, uh-huh, and the phone number that's in line is actually her number and the email address on file is her email.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And that is also the number she's calling from.
[AGENT][NEUTRAL] Yeah, I see that.
[AGENT][NEUTRAL] [PII]. OK, you can go ahead and transfer her over.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, well, well, will you let me know on this one since I haven't come across one like this before?
[AGENT][NEUTRAL] In the meantime, I'm
[AGENT][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.
[CUSTOMER][NEUTRAL] I don't
[CUSTOMER][NEUTRAL] Yeah, just, I mean you can just send me a message. I mean teams or something just kind of hey you know.
[CUSTOMER][NEUTRAL] Whatever.
[AGENT][NEUTRAL] I'm pulling up their policy now cause like I said, I believe it does have something to do with it being an accident diagnosis.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] Uh, I don't really do med link, so.
[CUSTOMER][NEUTRAL] Uh,
[AGENT][NEUTRAL] I might
[CUSTOMER][NEUTRAL] I see.
[CUSTOMER][POSITIVE] She's really nice. She's just, like I said, she's just kinda wanting before she starts trying to chase the stuff down again because she thought she had everything.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEGATIVE] And when I read that and then looked at the documentation, I was not clear.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] OK, now I'm looking at the policy, so just making sure that I'm.
[AGENT][POSITIVE] At least where I'm going with it.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][POSITIVE] It's about the best I can do.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] But you can go ahead and transfer her over and um.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Well, I continue to review this.
[CUSTOMER][NEUTRAL] OK, you sure?
[CUSTOMER][NEUTRAL] You ready?
[AGENT][NEUTRAL] Yeah, I think so.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] As as ready as you're gonna get.
[AGENT][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.
[CUSTOMER][NEGATIVE] Yeah, I'm saying I'm not getting anything like
[CUSTOMER][NEUTRAL] I mean, I'm looking, I've looked at the policy as well, and I mean it's not clear to me.
[AGENT][NEUTRAL] And we do have.
[AGENT][NEUTRAL] Yeah, we do have her here. OK, I was just looking at the EOB now to make sure.
[CUSTOMER][NEUTRAL] Yeah, and that's yeah this one.
[AGENT][NEUTRAL] But I wasn't seeing any, anything else.
[CUSTOMER][POSITIVE] OK. Well, thank you so much for this. I appreciate you.
[AGENT][POSITIVE] No problem. You're welcome.
[CUSTOMER][POSITIVE] And if I don't talk to you again, have a great weekend.
[AGENT][POSITIVE] You too. Hope you feel better.
[CUSTOMER][POSITIVE] Thanks, [PII]. I mean, this is happening like fast and it was 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.
[AGENT][NEUTRAL] Oh.
[AGENT][POSITIVE] OK. Thank you, [PII]. Bye.
[CUSTOMER][POSITIVE] All right. Bye-bye. Thank you. Bye.
[AGENT][NEUTRAL] Good afternoon. Is this uh Ms. [PII]?
[CUSTOMER][POSITIVE] It is fine
[AGENT][NEUTRAL] Hi, Ms. [PII]. My name is [PII]. I'm in the claims department, and I'm sorry for the delay. I was looking over your documents. [PII] transferred you over and you had some additional questions in regards to a claim for [PII]. We were, looks like we're asking for some additional, uh, information, uh, to support the claim.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] And um it, it does look like I have the claim form, the explanation of benefits from the primary insurance, and I also see the billing uh that you got a copy of that UBO4 form from the facility, um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, where he had the emergency room treatment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Now, um, it does look like they're asking for some additional supporting documentation. Since we do have the procedure and diagnosis codes, it is a rather um lengthy request, but what it basically um is asking for is some additional supporting documentation. Um, and what that would consist of in this situation because it appears we have the billing and the EOB information um that includes that diagnosis.
[AGENT][NEUTRAL] We're looking for possibly the um.
[AGENT][NEUTRAL] The hospital, either the emergency room documentation or what they call a um an admission and discharge summary from the emergency room.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK, admission and discharge summary admission.
[AGENT][NEUTRAL] Yes, or it could just be the they also call it an ER documentation. Um, sometimes you might be able to find it if you have a patient portal, um, that has access to that information from that facility. They might, um, you might be able to uh either view that document or request it right through that portal if you have access to a portal.
[CUSTOMER][NEUTRAL] Oh, it says
[CUSTOMER][NEUTRAL] OK, I see it here.
[CUSTOMER][NEUTRAL] No, what did you say it's also called the ER what?
[AGENT][NEUTRAL] It could just be um an EED or ER which means emergency department or emergency room, um.
[CUSTOMER][NEUTRAL] Your
[AGENT][NEUTRAL] Uh, notes or documentation. So a lot of times when you are seen in the emergency room, you might see a triage nurse, and then you'll have to wait for like the physician. So, what, I believe that that could be the supporting documentation that's being requested. And like I said, it could be those ER either the ER notes or emergency department notes or a hospital admission and discharge summary.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So, and what that will do is just give us a little bit more support and documentation for the claim.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK, and also you don't, could you, uh, would they want, uh, I have, I don't think I submitted this, but they sent me um.
[CUSTOMER][NEUTRAL] What's there what are they calling this itemized statements and transaction history but.
[CUSTOMER][NEUTRAL] It to me there's not a whole lot different than what that other thing they said was that has codes on it but.
[AGENT][NEUTRAL] Right. And like I said, since
[AGENT][NEUTRAL] Yeah, and they're gonna be pretty much the same codes that are that we already have on that billing form that you obtained that UBO4 form. Um, I believe they're gonna be the same, it's gonna be the same information as either the revenue or procedure code, um, and they'll have that service date and then of course the charges for each service. um, but I think.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, that's what it is, so we don't need that.
[AGENT][NEUTRAL] Yeah, and I, I don't think so because like I said, it looks like because we already have that other, the only thing that would be missing is like I said, that supporting documentation and um that would, like I said, include either that hospital admission and discharge summary or either that the emergency room note.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, OK, OK, so if I get those things that they'll look at this again and we've never had a claim and they had APL for years.
[CUSTOMER][NEUTRAL] Um, I don't think we've ever had a claim. I don't know, but anyway.
[AGENT][NEUTRAL] Well, and I think, and I'm, I'm thinking that what's going on here is, um, because of the way they coded it, they coded it it's just an open bite is the diagnosis code. And I guess um [PII] did say that it, it was, um, you, you were bit by, he was bit by a dog.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Or an animal.
[CUSTOMER][NEGATIVE] Yeah, German shepherd, yeah, it's pretty bad. It's on both hands, yeah.
[AGENT][NEUTRAL] Yeah, yeah.
[AGENT][NEUTRAL] Yeah. So because it's, it's just kind of a generic open bite, I think that that's what they're looking for is just that documentation um to support that because the diagnosis isn't real clear.
[CUSTOMER][NEUTRAL] OK, OK, OK, well I'm, I'm gonna call him and ask him to.
[CUSTOMER][NEUTRAL] Send whatever they can that.
[CUSTOMER][NEUTRAL] They they're requesting, so, OK, and then I can just fax it um to the claims department that I like I did the other ones.
[AGENT][NEUTRAL] Yes, you can fax it. um, do you have an online service, uh, account?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Do you know?
[CUSTOMER][NEUTRAL] What do you, what do, what do you mean?
[AGENT][NEUTRAL] Because you, you can
[AGENT][NEUTRAL] Um, well, we have an online portal that you can, um, actually upload claims through um through that way if you prefer or if you wanna fax it or mail it, you also have that option.
[CUSTOMER][NEUTRAL] Well
[CUSTOMER][NEUTRAL] I'll probably just fax it, but we we have um.
[CUSTOMER][NEUTRAL] You know we pay for our employees their APL and so but I've never uploaded documents to that. I don't remember ever seeing that function it's probably.
[CUSTOMER][NEUTRAL] I don't know.
[CUSTOMER][NEUTRAL] I'll probably just fax it. I, I looked around and I didn't see it before.
[AGENT][NEUTRAL] Well, what it is you'd have to, yeah.
[AGENT][NEUTRAL] OK, well, we have a secure portal where you can go and view your policy, upload claims, on that kind of information. So I'm not sure if that was never provided to you. Um, I'd be happy. Now, what, what would happen is you just need to go and create a username and password and, and then access it that way.
[CUSTOMER][NEUTRAL] I don't think so.
[CUSTOMER][NEUTRAL] You know what, maybe it's because.
[CUSTOMER][NEUTRAL] I mean I can get into our APL account as the employer, but I'm thinking since we have a broker probably he's he's the one that has that, not us, you know what I'm saying?
[AGENT][NEUTRAL] Ah, OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] I bet you that's so I could probably even email it to him and he could forward it to you guys.
[AGENT][NEUTRAL] Which you could sign up as um
[AGENT][NEUTRAL] Yeah, well, it does look like you have an active account and it does show um that information out here so it's possible it might have been information so usually it's the insured that sets that up or it could be the broker and you know with the insured, but that is your information so you can submit it that way or you can um submit through the secure fax. Either one is is fine it's what your preference is.
[CUSTOMER][NEUTRAL] But it's just
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][POSITIVE] OK, OK, that sounds good so OK, all right.
[CUSTOMER][POSITIVE] Well, thank you for your help.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] You're welcome. And did you have any other questions, Ms. [PII]?
[CUSTOMER][NEUTRAL] I don't think so. That's all.
[CUSTOMER][NEUTRAL] See what they can provide and go from there.
[AGENT][NEUTRAL] OK, and if you have any additional questions feel free to reach out to us and uh but like I said it, you should be able to obtain those documents fairly uh easily. If, like I said, if you don't have that portal, um, then you'd probably would have to um maybe call or or and request but um if they allow you to um have access to the patient portal with the hospital, you may be able to obtain the documents through there.
[CUSTOMER][NEUTRAL] What?
[CUSTOMER][NEUTRAL] Oh yeah, OK, OK, I can ask him that, yeah, OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All right sounds good.
[AGENT][POSITIVE] Well thank you so much for calling APL. I hope you have a great rest of your day and a great weekend.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] Uh, OK, you too. Thank you.
[AGENT][POSITIVE] Thank you. Bye bye.
[CUSTOMER][NEUTRAL] Bye.