AccountId: 011433970860
ContactId: 20f03fcc-7d5c-4e9b-94a0-801a9106ee36
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 800479 ms
Total Talk Time (AGENT): 521110 ms
Total Talk Time (CUSTOMER): 258288 ms
Interruptions: 3
Overall Sentiment: AGENT=0.3, CUSTOMER=1.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/13/20f03fcc-7d5c-4e9b-94a0-801a9106ee36_20250513T13:44_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey [PII], it's [PII] in care team. Um, I've got a broker on the line that is checking on claim status denial, and he says that it should be processed, um, because it's a new injury. Can I give you that, uh, policy number for you to take a look and maybe help him out?
[AGENT][NEUTRAL] Hey.
[AGENT][NEUTRAL] Yeah, sure, go ahead.
[CUSTOMER][NEUTRAL] Policy number is 2605149.
[AGENT][NEUTRAL] OK, is it a claim that we've already denied and they're saying that they feel like it should have been processed or is it like a timely thing?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEGATIVE] No, it's a claim we've denied. We said the benefits exhausted but.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] For [PII] and I verified him. His callback number is the one on the screen. He's with that CBOA, um.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] He said that this is a new accident. She had a prior knee injury, but this is a new accident, and he said that this should be considered since it's a new accident.
[AGENT][NEUTRAL] OK, what, uh what claim number specifically are we looking at? Do you know?
[CUSTOMER][NEUTRAL] Uh, the 399-360-00399.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so let me just look real quick to kinda.
[AGENT][NEUTRAL] OK, so they're saying new accident.
[AGENT][NEUTRAL] Previous injury, but it's unrelated.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Unrelated, yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I wonder was it like the same knee?
[AGENT][NEUTRAL] And that's why.
[AGENT][NEUTRAL] Extended treatment. That's why we did not.
[CUSTOMER][POSITIVE] Usually I, I've talked to him several times and he's usually pretty sharp about these. Seems like he knows this stuff, so.
[AGENT][POSITIVE] Yeah, I mean, yeah, that's great. I mean, I'd rather, you know, than for me to be kind of philandering about, you know what I mean?
[AGENT][NEUTRAL] OK, let's see, let me get the policy and the.
[AGENT][NEUTRAL] Information pulled up.
[AGENT][NEUTRAL] What was his name?
[CUSTOMER][NEUTRAL] His name is [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] He's with that CB Nola.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK. um, OK, I'm ready when you are.
[CUSTOMER][POSITIVE] OK, I'll introduce you and then I'll release it thank you.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] OK, [PII], I've got [PII] on the line and she's gonna assist you with looking at that claim, OK?
[CUSTOMER][POSITIVE] Got it thank you. Thank you bye bye.
[AGENT][NEUTRAL] Hey [PII], how are you?
[CUSTOMER][POSITIVE] Hey good morning it's great how you doing?
[AGENT][POSITIVE] I'm doing well.
[AGENT][NEUTRAL] Um, so Ms. [PII] was saying that we have a claim for Ms. [PII] that has been denied for what is a new accident.
[AGENT][NEUTRAL] And um and so we're we're kind of needing that to be reevaluated is that that kind of the gist of what's going on here? OK.
[CUSTOMER][POSITIVE] Correct, correct.
[CUSTOMER][NEUTRAL] So, so basically, it looks like the person that took a look at it was think it, it appears that they were acting like it was the, she injured herself twice, unfortunately, in two months. She had a knee injury.
[CUSTOMER][NEUTRAL] And she had an ankle injury. The ankle injury new happened on [PII], so it's a whole new claim, and the gentleman or whoever had looked at it, it looks like they said they exhausted their benefits, but that's really on the old claim where she exhausted her follow-up visits. But on the new claim she hasn't received anything because it's a whole new injury and it's a different diagnosis and body part.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Gotcha. So, I see on this note from 58 reports on [PII], she rolled her left ankle when she stepped out of the truck into a parking lot, causing her to fall to the ground.
[AGENT][NEUTRAL] Does that sound right? OK.
[CUSTOMER][POSITIVE] Correct, correct, and the other injury was a knee injury, correct.
[AGENT][NEUTRAL] OK, and the previous injury was to the knee.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right, um, let's see.
[AGENT][NEUTRAL] OK, so what I'm going to do is I am going to because I'm trying to like.
[AGENT][NEUTRAL] Look at the diagnosis codes and stuff just because like I'm trying to figure out why this would have been.
[AGENT][NEUTRAL] You know, associated together, um.
[AGENT][NEUTRAL] Just to kind of get a better understanding of where the insured's mind was when they were or the examiner's mind was, you know, when they were processing, but, um.
[CUSTOMER][NEUTRAL] A lot of times
[CUSTOMER][NEUTRAL] Well, in, in, in their defense, she sent, um, multiple follow-up visits from the original injury. So she, in the system, they, they probably saw like 4 follow-ups from her, uh, initial injury, so they might have just thought it was that.
[AGENT][NEGATIVE] Gotcha.
[AGENT][NEUTRAL] Got you. OK, so it was just kind of all together and they were like, oh, OK.
[CUSTOMER][NEUTRAL] So, um,
[CUSTOMER][NEUTRAL] And, and
[CUSTOMER][NEUTRAL] Well yeah, they, I think it was just close in proximity in time but and at first we didn't send the claim form right away.
[AGENT][NEUTRAL] Yeah, it was.
[CUSTOMER][NEUTRAL] So, what I was getting at was we didn't send the claim form um with, with, with the initial injury, um for the new injury, we sent it separate so they might have just thought it was a continuation of the old on[PII]
[AGENT][NEUTRAL] OK, got you, OK, alright, so.
[AGENT][NEUTRAL] Where, where was she treated initially? Because the diagnosis code on this note from [PII] indicates that this is like a subsequent visit.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] So,
[AGENT][NEUTRAL] It's not showing that it's like an initial.
[AGENT][MIXED] Top thing. I don't, I don't know why they would do that. Yeah, and that could have been the other issue too is that they're, they're kind of indicating that it's not.
[CUSTOMER][NEUTRAL] OK, so the diagnosis code.
[AGENT][NEUTRAL] Like the first time they've treated her for this, which is why they may have associated this with the previous.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Like with everything else, you know what I'm saying? So that's what, um.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] That's what I'm trying to look at as well.
[CUSTOMER][NEUTRAL] That was her first visit because it happened on it, it happened on [PII] and that was her first visit due to the ankle. So it, it could be them have just done it, um, could have easily just put the incorrect code. I see that happen unfortunately, a lot more times than you would think, um, because a lot of these people are rushing when they do it, you know what I mean?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah. Oh yeah, no, I believe you.
[AGENT][NEGATIVE] I see so many errors with coding.
[CUSTOMER][NEUTRAL] And what happens is these people rush through it, you know.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] And it's such a burden to try to chase people down because they're like, I ain't got time for this, you know, they're, cause these doctors nowadays are like turning and burning, you know.
[AGENT][NEUTRAL] It, it really is.
[AGENT][POSITIVE] Yeah, they really are.
[CUSTOMER][NEUTRAL] Like to make money, these guys, they have to see a high.
[CUSTOMER][NEGATIVE] They have to see a high amount of people so they're just hurry up and rushing it through and admins rushing it through, you know, um, so.
[AGENT][NEUTRAL] Yeah, and even the billing and coding departments are trying to put out so much so fast that they're just not they're just not I don't even want to say that they're not paying attention, but it's like they, you know, that A and that S are right there beside each other so it's real easy to, you know, do a keystroke error and you, you meant to use an A, but you use the S and just didn't catch it, so.
[CUSTOMER][POSITIVE] Absolutely.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK
[CUSTOMER][POSITIVE] Yep, that's exactly right, that's exactly right.
[AGENT][NEUTRAL] Um, I will, so the.
[AGENT][NEUTRAL] The bill that we have from 58.
[AGENT][NEUTRAL] It does indicate sprain of the ankle and everything. But the procedure, there are a couple of procedures that are on here that are not necessarily ankle-related. Like it's her, um,
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It's her chiropractic adjustment and everything from her back.
[AGENT][NEUTRAL] There's like heat and cold pack, there's electric stimulation, um, and they do mention that, like they did put that they were gonna continue to treat her for that.
[CUSTOMER][NEUTRAL] You know, and I told her that I, I.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so it looks like they, I've, oh, I've seen this happen before with some of these places they put like a cumulative stuff on there from the past as well on these bills and all it does is confuse the claims because that's something from a prior claim, you see what I'm saying?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Right, yeah.
[CUSTOMER][NEUTRAL] So I'm thinking, I'm thinking it's like some of these places that have like super bills and stuff like that, that do, um, they have like a cumulative stuff on there, a cumulative things on their charts instead of just putting what it was just for this, for this specific incident, you know.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, um, because they do mention it.
[CUSTOMER][NEUTRAL] So, um, you just tell me what you think I need to do.
[AGENT][NEUTRAL] Let's see. Cause they do, I mean, it is reported that she rolled her ankle, that she didn't realize there was a pothole there when she got out and it causes like a sprain basically to her ankle. So she had swelling and pain and, you know, but then they go into um
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] You know, they mentioned that she was having some issues with walking and standing because of the pain and the swelling, her discomfort. But then they go into, they also noted vertebral joint misalignments, muscle spasms, stuff like that in her cervical, mid thoracic and lumbar regions, which doesn't have anything to do with her ankle.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then they go in, they go back into her X-ray of her ankle, you know, to, to report that. But then the treatment is in regards to her back and then they put ice on her ankle and they did an ultrasound.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So they're, they're kind of going back and forth on what they're treating and, and what they're acknowledging. So, like you said, I think because of the previous injuries and them being kind of close, you know, in time within a couple of months of each other, um, that they're still probably treating her for previous stuff in addition to the new and they're combining it all into one note.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, so what I'm trying to think because we do have.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I'll tell you what, I'm going to get the examiner and maybe even the supervisor um of this product to review it and kind of notate that, you know, this did, this is a new injury even though she is being treated for old injuries because I think at the very least she may be able to get um consideration for that office visit and um the X-ray that was done.
[AGENT][NEUTRAL] Um, so, because she didn't have a fracture or anything like that. So I think maybe at the very least she could get consideration for those. As far as the extended treatment denials for that chiropractic care and everything, I think those denials are probably valid that she's already, you know, exhausted all of that because they can bind it all up under this one visit. Um, but we might be able to reconsider the office visit and the X-ray.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, OK, well, whatever you can do on your side, and, and I'm going to, um, tell her they need to clean up their stuff because it's, it's, um, needs to be separated per injury and per diagnosis, even if she had something else going on from the past, you can't put that on the current paperwork it just confuses the process, you know.
[AGENT][NEUTRAL] Does that sound OK?
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] For sure.
[AGENT][NEUTRAL] Right. Yeah, it does. And like I said, that diagnosis code doesn't help because this is a new injury, but they're treating it as a follow-up. So, you know, all they said is that they're gonna continue to treat her per their exam findings and continue existing treatment plan.
[AGENT][NEGATIVE] Um, and then they, they instruct her to just stay off of her foot and apply ice and take, you know, basically Tylenol or ibuprofen or whatever for pain. So they're treating it as a subsequent visit, but she just got injured that day. So, you know, like, that does not help because for the, you know, for the claims world, it does indicate that this is not new. Um, this is, uh, an existing injury. And so,
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] We can look at her, uh, go back and look at her, um, like claim form where she says this is when this happened it does say in this note.
[AGENT][NEUTRAL] You know that this happened on this day so um I'll go back and see if we can't review that for at least the, the physician's office and the X-ray that took place, um, and then I don't know that there will be anything else I would have truly I would have to go into her policy and see what benefits would be available but we'll we'll consider all available benefits. Those are just the two that I feel like are notably able to be considered based off of what I see.
[CUSTOMER][POSITIVE] OK, well I appreciate your time thank you very much and I will circle back to you.
[AGENT][NEUTRAL] Of course.
[AGENT][NEUTRAL] OK, I will have them review that as soon as possible. I would ask that you allow a couple of days at least, um, but, but yeah, um, we should, we should get right on that by this, by the end of the day hopefully.
[CUSTOMER][NEUTRAL] And it it it it.
[CUSTOMER][POSITIVE] Perfect thank you so much.
[AGENT][POSITIVE] You're very welcome, [PII]. Is there anything else I can do for you?
[CUSTOMER][POSITIVE] I appreciate you.
[CUSTOMER][POSITIVE] That's it. Have a great day.
[AGENT][NEUTRAL] OK, you too.
[CUSTOMER][POSITIVE] Thank you take care bye bye.
[AGENT][NEUTRAL] Yes sir bye bye.