AccountId: 011433970860
ContactId: 270fdd30-9a13-412f-9a86-8769c0f2dcf1
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 876979 ms
Total Talk Time (AGENT): 476027 ms
Total Talk Time (CUSTOMER): 266924 ms
Interruptions: 3
Overall Sentiment: AGENT=0.5, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/23/270fdd30-9a13-412f-9a86-8769c0f2dcf1_20250123T22:07_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How can I help you?
[CUSTOMER][NEUTRAL] Hey, [PII], this is [PII]. How are you?
[AGENT][POSITIVE] Doing well [PII] thank you how are you?
[CUSTOMER][NEUTRAL] Good. I have an insured on the phone. Um, it's regarding policy 740,240.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And she's calling about a date of service up for her [PII].
[CUSTOMER][NEUTRAL] So the latest one I found was 354-300-009.
[CUSTOMER][NEGATIVE] It looks like we denied that as a.
[CUSTOMER][NEUTRAL] Duplicate to a claim previously submitted.
[AGENT][NEUTRAL] OK, 354-300-09?
[CUSTOMER][NEUTRAL] Mhm and so I found the other one under 353-633-5.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And that's the one that we cited that we're requesting medical records.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So,
[AGENT][NEUTRAL] I see that uh huh so we're probably waiting for the medical records. um, I believe [PII] is handling.
[AGENT][NEUTRAL] These claims, um, they'll be, I mean I can try to let her know that that's what's going on. So yeah, it looks like it was denied a duplicate because it's pending for the medical records. I would assume, yeah.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK, so the insured sending the same bill, is that what it is? Is that why it's denying as a duplicate?
[AGENT][NEUTRAL] Um, probably I mean I'd have to pull the image up to look at that, but that's more than likely if it was denied as duplicate, that's usually why? because we already have that claim on file and so we might be waiting obviously in this particular case we're waiting for those medical records, but I could pull it up and take a look. I mean, did you need me to talk to her?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] If you don't mind, um, I don't know when we initially requested the records. Do we do like follow ups or something about the records if we don't get them at a certain time or no?
[AGENT][NEUTRAL] Um, I believe we're supposed to, yes, but, um, like I said, I know these are being handled by [PII], so.
[CUSTOMER][NEUTRAL] OK. If, if you don't.
[CUSTOMER][NEUTRAL] Yeah, if you don't mind um intercepting the call.
[AGENT][NEUTRAL] OK, and she's been verified?
[CUSTOMER][NEUTRAL] She's been verified, yeah.
[AGENT][NEUTRAL] And that's all her information there, uh, I'm sorry, her phone number, yeah, mhm.
[CUSTOMER][NEUTRAL] The phone number, the phone number, yes, it is.
[AGENT][POSITIVE] Alright, great.
[CUSTOMER][POSITIVE] All right. Thank you, [PII].
[AGENT][POSITIVE] Sure, I'm gonna pull up those records now thank you.
[CUSTOMER][POSITIVE] OK, you're welcome and here she comes.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Hello, Ms. [PII].
[AGENT][POSITIVE] Good afternoon.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Hi this is [PII] in the claims department. How are you?
[CUSTOMER][POSITIVE] I'm good.
[AGENT][NEUTRAL] Good, so I understand you have a question about uh the claim that was processed for your [PII] data service, is that right?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So let me just
[CUSTOMER][NEUTRAL] Can you hold on one second?
[CUSTOMER][NEUTRAL] Can you hold on one second?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, hold on one second.
[AGENT][NEUTRAL] Of course.
[CUSTOMER][POSITIVE] OK, I'm sorry.
[AGENT][NEUTRAL] That's OK.
[AGENT][NEUTRAL] OK, so, um, Ms. [PII] transferred you over to me. I understand you have a question about the [PII] claim being denied duplicate, is that right?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] I was just checking claim status and she said it was paid and I told her no, I don't think it was.
[AGENT][NEUTRAL] Right, so it looks like for that [PII] data service we did request medical records and we are currently waiting for those records to come from the provider's office. So what happened, it looks like is this particular claim that she was referring to the 354-3009 um was denied as a duplicate.
[AGENT][NEUTRAL] It's a duplicate to a claim already on file, so in other words.
[CUSTOMER][NEUTRAL] It's fine.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I was just checking that.
[AGENT][NEUTRAL] Yeah, now I do look like there was a couple of other claims that have been finalized, um, but that particular claim, uh, we're waiting for those medical records and it looks like that claim is the 353-633-5.
[CUSTOMER][NEUTRAL] That's right. Can you tell me, oh, before you, um, get done with mine, I do have a question. Um, I had to be, I fractured my back and I had to be taken by ambulance. Do you guys take ambulance, um.
[AGENT][NEUTRAL] I'd have to look to on your policy to see if those ambulance um if you can submit uh I mean you can obviously submit that claim. Let me just check your benefits. Just bear with me for one moment. I'd have to pull up your policy and just see if you actually have that ambulance benefit, so bear with me for just one moment and let me do that.
[CUSTOMER][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah sometimes it's an extra rider on your policy.
[AGENT][NEUTRAL] Um, so let me just pull your policy benefits up.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I'm just waiting for it to load. Bear with me please for just one moment, sorry.
[CUSTOMER][NEUTRAL] Oh, you're fine.
[AGENT][NEUTRAL] And just to let you know it is a verification of your coverage, not a guarantee of payment. I do see the ambulance benefit uh listed on your policy, um.
[AGENT][NEUTRAL] And that policy, uh, benefit.
[AGENT][NEUTRAL] Is $2500 so we will need that um due to the type of policy that you have, it does require the actual charges so you want to make sure that you get uh an itemized bill with those procedure and diagnosis codes and just be sure that it is related to that injury, um.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It was, that's the reason I was taken to the hospital, um, cause when I fell, I couldn't get up, so paramedics had to come get me. Um, I do have medical records.
[AGENT][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] I'll just, now I've never had to submit an ambulance bill, so you know if you guys will take, like I don't know if they give you a UB. I don't think they even have a UB or I know they'll give it itemized, but I know you guys need a UBO4 with ambulance, what kind of form do y'all need?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Usually they um ambulance is like a more of a professional fee um that they they don't necessarily use the UBO for unless it's being billed by the facility that hospital so usually it's on a form called a CMS 1500, so that's C like Charlie.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] M like Mary, S like Sam, and 1500. So usually that's how they bill their charges um but we can't accept that itemized bill as long as it has the procedure and diagnosis codes so it doesn't necessarily have to be that form we'll just need like I said that uh that itemization of charges because we do need the actual charges and then like I said as long as it that has that procedure and diagnosis code information.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK, and even though you guys already paid out the benefit for the actual um hospital visit, you guys still paying additional for the ambulance?
[AGENT][NEUTRAL] Yes, it's a separate benefit because it comes as a um uh a separate benefit under your plan.
[CUSTOMER][NEUTRAL] Because
[AGENT][NEUTRAL] I believe, let me.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It's listed here on your policy, uh, certificate, so.
[AGENT][NEUTRAL] Um,
[CUSTOMER][POSITIVE] I'm glad I asked because I was in an auto accident, uh.
[CUSTOMER][NEUTRAL] Gosh, it's been a while and I did some y'all did pay out the benefit from the, the hospital, but I never submitted my ambulance bill. I can still send it in.
[AGENT][NEUTRAL] Yes, there is no filing limitation for your policy, um, at least, uh, right now there's no um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] We don't, we don't, um.
[AGENT][NEUTRAL] We don't have that filing limit on these policies. So sometimes you have a filing limitation under most of your major medical plans, um, but this particular, uh,
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Excuse me, this particular um policy we're not um using that.
[AGENT][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Now, when I submit the ambulance bill with the medical records, um, do I need to submit the original claim with you or do, like, how do I submit additional documents?
[AGENT][NEUTRAL] So you would just submit it um and you can reference do you have the information for that previous claim so what we're gonna do is we're gonna go back and look to see um.
[AGENT][NEUTRAL] And just uh verify that there was an actual accident that occurred. Cause like I said, it does have to be related to the accident and it does have to have, like I said, that diagnosis that's related to the accident. So as long as that information's there, we'll be able to know that it's related to that particular uh incident.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yes it is.
[CUSTOMER][NEUTRAL] OK, it's gonna have the same data service and it's gonna have, I guess, where they took me to the same hospital that added the, the bills to. OK, um, I'll get that for you guys and then you also stated that there was a fee that had already processed. Can you tell me which ones those were?
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Because there was a few that was pending for records that I submitted back in November.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So I show the two most recent, let me just double check this.
[CUSTOMER][NEUTRAL] Cause on my portal it's still showing pending.
[AGENT][NEUTRAL] So I show a claim finalized for you data service 12-222024.
[CUSTOMER][NEGATIVE] Yes, that was, that's the night I fell and that's the, that's the fracture.
[AGENT][NEUTRAL] OK, and then there was also one for let me see that was claim 3551086 that was finalized.
[AGENT][NEUTRAL] On 113 and then on 114.
[AGENT][NEUTRAL] A claim for 125-2024 for emergency room for you. That was finalized as well.
[CUSTOMER][NEUTRAL] OK, but the ones for my son and my husband, those are still pending for records, right?
[AGENT][NEUTRAL] They are, yes.
[CUSTOMER][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] Yeah at this time we're still waiting for those records.
[CUSTOMER][NEUTRAL] OK, alright, well I will um send over my ambulance bill and just um cause I do everything online, so when I, do I have to still submit the.
[CUSTOMER][NEUTRAL] Your guys' accident detail paper that I filled out?
[AGENT][NEUTRAL] Yes, the accident claim form is required for any claim, and that's just so that we have it in our files so because it is an accident only policy, it does need to have that accident claim form that tells us the details, the date of the accident, the details, and then again because your policy is particularly uh for actual charges we need those charges as well.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, can I submit the original, um, of the accident form for the [PII] and the date, the original, the hospital one, or do you need a new one?
[AGENT][NEUTRAL] Um, you can, as long as it's the same accident and you're speaking up for the, um, for that ambulance, right?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Yes, yes, it was a, the, the one on top of the annal was 1220. That was a fracture.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So if it
[AGENT][NEUTRAL] Yeah, so if that if we've already paid that claim and you've already filed an accident claim form you can include a copy of it if you'd like, but we already have the claim on file so we know what happened as long as that information like I said, as long as we can tie it back to that accident, that's what's most important so that data service like I said in that procedure and diagnosis code match everything goes with that claim we'll just go ahead and and review that claim form you sent in prior.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh, how does the diagnosis code match in the ambulance bill if they don't know what, like what the outcome was?
[AGENT][NEUTRAL] Well, they should have a they should have some sort of diagnosis um because they'd have to bill insurance companies just like your, just like any uh any uh services that are, you know, provided for you like so for instance, with this particular one, they're gonna know that.
[CUSTOMER][NEUTRAL] Oh, OK, I see what happened.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] It was some sort of injury that you either fell or you know whatever happened in the accident detail, the, the ambulance is gonna have some sort of diagnosis that will go with that because they have to bill insurance companies too, so they have to have some sort of diagnosis in addition to their procedure code.
[CUSTOMER][NEUTRAL] 00, OK, so this, OK, I see what you're saying, and they probably got with the hospital. I, I see what you're saying. They're gonna, it's gonna show that I failed because I mean they knew I fell. OK. OK. Oh.
[AGENT][NEUTRAL] Right, exactly, yeah, they'll have that information, mhm.
[CUSTOMER][POSITIVE] OK, well thank you for your time I appreciate it you have a good afternoon.
[AGENT][NEUTRAL] You too, Ms. [PII]. Did you have any other questions?
[CUSTOMER][NEUTRAL] No, ma'am.
[AGENT][POSITIVE] Alright, thank you for calling APL thank you for being a customer and I hope you have a great evening.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] You too bye bye bye bye.
[AGENT][POSITIVE] Thank you, bye bye.