AccountId: 011433970860
ContactId: 22acd3be-9a87-4453-b4ca-825eb0abd683
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 578429 ms
Total Talk Time (AGENT): 186858 ms
Total Talk Time (CUSTOMER): 136387 ms
Interruptions: 0
Overall Sentiment: AGENT=0.7, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/30/22acd3be-9a87-4453-b4ca-825eb0abd683_20250530T19:04_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hey [PII], this is [PII]. I have filed a claim online and I was trying to check the status on that. When I looked online it it says amount paid 0, so I was just checking on.
[CUSTOMER][NEUTRAL] Um
[AGENT][NEUTRAL] The
[CUSTOMER][NEUTRAL] If I needed something else to turn in or what I needed to do.
[AGENT][NEUTRAL] OK, well, I can definitely check on the claim status for you. And Miss [PII], may I have a good contact number in case we're disconnected and your policy number?
[CUSTOMER][NEUTRAL] Uh, the phone number is [PII].
[CUSTOMER][NEUTRAL] And I'm driving so I don't have the policy. I can't get to the policy number right now.
[AGENT][NEUTRAL] Oh, OK, it's OK. I can also look it up with your social if you like.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Welcome.
[AGENT][POSITIVE] And I'm ready when you are.
[CUSTOMER][NEUTRAL] OK, [PII].
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] I'm just waiting for the policies to populate here.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] And Miss, can you verify your date of birth, your mailing and email address on file?
[CUSTOMER][NEUTRAL] Yeah, [PII] address [PII].
[CUSTOMER][NEUTRAL] We just moved uh [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. So we received two claims on, oh, this is one claim, OK, it's two different lines. I'm sorry. Um.
[CUSTOMER][NEUTRAL] It it is one claim, yeah, that's OK.
[AGENT][NEUTRAL] So the it looks like it was denied stating that it's not a covered loss under the policy. Um we only pay out for loss, um.
[AGENT][NEUTRAL] Identified on the schedule of benefits. So it wasn't a covered service.
[CUSTOMER][NEUTRAL] What, what do you mean a loss? I, I filed on this for breaking bones several times, so I'm not sure.
[CUSTOMER][POSITIVE] What that means a lot.
[AGENT][NEUTRAL] So let me take a look. Hold on one moment.
[CUSTOMER][NEUTRAL] Yeah, because I, I have the accident policy and I have broken several bones and filed claims and received um.
[AGENT][NEUTRAL] So there's
[CUSTOMER][NEUTRAL] Benefits.
[AGENT][NEUTRAL] There are 2 lines on here for durable medical equipment. So for those lines, the denial reason.
[AGENT][NEUTRAL] Is that the benefits payable under this certificate are limited to those outlined in the schedule of benefits that will only pay out for what's listed. So durable medical equipment is not covered under this policy.
[CUSTOMER][NEGATIVE] OK, I, I get that, but I, I broke a foot and I have medical bills associated with that.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] Right, so for those, I'm getting ready to give you the denial reason for those. I'm just going through the lines on the claim.
[CUSTOMER][NEUTRAL] Oh, OK, got you.
[AGENT][NEUTRAL] So for those, they were all denied for the same reason, looks like, let me see if there's any more.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Alright, so it's requesting an itemized bill with diagnosis codes.
[CUSTOMER][NEUTRAL] Diagnosis
[CUSTOMER][NEUTRAL] Um
[AGENT][NEUTRAL] And that's so we can
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I said the EOB does that not have what you need on it?
[AGENT][NEUTRAL] Usually it doesn't. It usually just shows the
[CUSTOMER][NEUTRAL] Because it said
[AGENT][NEUTRAL] Go ahead, I'm sorry.
[CUSTOMER][NEUTRAL] No, go ahead.
[AGENT][NEUTRAL] Um, the explanation of benefits usually shows what was done, like the procedure codes, but the diagnosis, why it was done isn't usually on there, but I'm pulling up the documents that you um sent in now so I can try to see if there's a diagnosis code somewhere we can use.
[CUSTOMER][NEUTRAL] Yeah, because, uh, the doctor's office printed me out a statement. I have the EOB, so I'm not sure what else I could get that has.
[CUSTOMER][NEUTRAL] What you're asking
[AGENT][NEUTRAL] And this is for a doctor's office or was it a hospital?
[CUSTOMER][NEUTRAL] It was emerge ortho.
[AGENT][NEUTRAL] So like an urgent care?
[CUSTOMER][NEUTRAL] Yeah, urgent care, which they have doctors there.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, and do you mind if I place you on just a brief hold? I'm just going through the documents here.
[CUSTOMER][POSITIVE] Yes ma'am, thank you.
[AGENT][NEUTRAL] You're welcome. Hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Yeah, these are um proc I mean, these are uh diagnosis, these are procedure. Yeah, here it goes.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, hello Miss [PII].
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] All right, thank you so much for holding. I apologize for that wait. So there, so you, so these are itemized bills, but they're your patient copy. So it only shows the procedure code, which is basically the treatment you received and what you pay for the treatment, but we need to know why. So, um, all you'll have to do is call the doctor's office and ask them for an itemized bill.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] With
[CUSTOMER][POSITIVE] Alright, I can do that.
[AGENT][NEUTRAL] ICD.
[AGENT][NEUTRAL] So the ICD 10 code, uh, those are the diagnosis codes.
[CUSTOMER][NEUTRAL] ICD.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So the ICD codes, the procedure codes, and then all the charges.
[CUSTOMER][NEUTRAL] OK, I'll call.
[CUSTOMER][NEUTRAL] OK, ICD and procedure charges.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, I will, um.
[CUSTOMER][NEUTRAL] Get those and then just submit it like I did the others.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Yes, ma'am, and then as soon as we receive it, we'll go ahead and continue processing.
[CUSTOMER][POSITIVE] OK, thank you for your help.
[AGENT][POSITIVE] You're very welcome. Was there anything else I can assist you with today?
[CUSTOMER][POSITIVE] No ma'am, thank you.
[AGENT][POSITIVE] All right, you're welcome. Thanks for calling APL. Bye-bye.
[CUSTOMER][NEUTRAL] Bye bye.