AccountId: 011433970860
ContactId: 29ecfb63-2553-4192-99b3-f88fdce3e235
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 599200 ms
Total Talk Time (AGENT): 378800 ms
Total Talk Time (CUSTOMER): 220277 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/2025/05/20/29ecfb63-2553-4192-99b3-f88fdce3e235_20250520T21:50_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] on the care team. How's it going today?
[AGENT][NEUTRAL] Good [PII] how are you?
[CUSTOMER][NEUTRAL] Alright, thank you. I've got a member on the line who has an HI policy, and I think there's just a bit of confusion as to what she submitted for this claim. She was trying to get the benefit for just hospital admission. Um, I do see when she gave me the data service, I see two claims for the same amount. However, both denial reasons are saying something different. She said that she did send um.
[CUSTOMER][NEUTRAL] The uh itemized statement that shows the admission and discharge time so I'm not quite sure if maybe there's just some missing information that we're just not seeing.
[AGENT][NEUTRAL] What
[AGENT][NEUTRAL] Sure, what's the policy number? I think it's the claim I might have.
[CUSTOMER][NEUTRAL] That is 25
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] She did mention she didn't fill out a claim form, um, so that's why I wasn't sure if maybe there's just some trouble linking um is 2552172.
[CUSTOMER][NEUTRAL] For uh [PII].
[AGENT][NEUTRAL] Yeah, that's the that's the claim I just processed.
[CUSTOMER][NEUTRAL] I was gonna say it looks like they were just today.
[AGENT][NEUTRAL] Yeah, um.
[CUSTOMER][NEUTRAL] So there were two for this state of service um for the [PII] or excuse me, [PII] um both are the same amount but they do look different so I'm not sure what was submitted. She said that she sent in the itemized statement with those admission and discharge times on the [PII].
[CUSTOMER][NEUTRAL] However, the one that I see on.
[CUSTOMER][NEUTRAL] What was that one on the [PII] I think.
[CUSTOMER][NEUTRAL] The [PII], um, that one stating that we need that information.
[AGENT][NEUTRAL] Right, because I see that there was a note in there. I did read the notes. So the first one she sent in on the [PII] was the itemized statement, but it just shows that there's no room and board charges, and it shows a clinic charge. The reason why it looks different is the previous adjuster keyed it under clinic. I keyed it under facility because she was at the hospital and that's.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] What that procedure means, um, if we don't usually if it's outpatient hospital, it's supposed to be under facility, um, but because that previous adjuster she saw the 510 revenue code on the itemized bill she put it under clinic because that 510 revenue code that's what it states on the actual um billing that she sent in so.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] She did send in um an additional page from her um and it just kind of like an aftercare summary however it doesn't give us any uh time doesn't give us any time so what I'm asking for is the um admit and discharge date and time, but I'll be happy to speak with her and explain that to her.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Yeah well I I appreciate you explaining that to me. I was a bit confused on that, so thank you. um, OK, yeah, I can go ahead and send her to you if you're ready.
[AGENT][NEUTRAL] OK, she's been verified?
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] And that's her number on the screen there, the [PII]? OK.
[CUSTOMER][NEUTRAL] Yeah, that, mhm.
[CUSTOMER][NEUTRAL] 1635. Yes, ma'am.
[AGENT][NEUTRAL] OK, you can go ahead and send it through when you're ready.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][POSITIVE] I appreciate your help thank you bye bye.
[AGENT][POSITIVE] No problem you're welcome thanks.
[AGENT][NEUTRAL] Hi, Ms. [PII].
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Hi, my name's [PII]. I'm on the claim support team and [PII] transferred you over to me to further assist you. So, um, apparently there's a little bit of, um, I don't know if it's misinformation or just um confusion. So we, um, originally received your claim with that um itemization of charges from the um [PII].
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] And so on that claims form or I'm sorry on that itemized bill, it does tell us that you were admitted to [PII] and discharged on the [PII]. However, it doesn't have any room and board charges it just shows a clinic visit, OK?
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] What we're needing is that admit and discharge.
[AGENT][NEUTRAL] Uh, date and time. Did you say you stayed overnight?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Yes ma'am, yeah, we, so that's, and that's why I'm so sorry. This is my new boy he's being fussy, um, that's why.
[AGENT][NEUTRAL] Of course, cause you got on the phone and you're
[CUSTOMER][NEUTRAL] or to sign up.
[AGENT][POSITIVE] Congratulations on the birth of your baby, by the way.
[CUSTOMER][NEUTRAL] So, um, but no, yeah, yeah, that's why I was because I actually went in a couple of days later and I wasn't admitted overnight but that time, yeah, we were, we, we had, we were moved from triage to a bedroom and then we stayed overnight and that's the only reason why I was trying to file so.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] You're saying that y'all need to see an itemized bill with that on there uh.
[AGENT][NEUTRAL] Well, right, because what you did send us on this latest, um, the after visit summary that shows what why you were there and that you were in the labor delivery recovery postpartum, it doesn't give us any time, it just gives us the dates of [PII] through [PII].
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] So those pages and then the rest are instructions of what your next steps are, you know, as far as once you were discharged. So, um, in order for your, your policy does um require at least 18 hours, um, and it can be an observation status or um a lot of times that they don't have a bed available they might just put it on as observation.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] But unfortunately, like I said, the itemized statement that we received only shows the clinic charge like it looks like it was you went in on the [PII] and then they have some charges on the [PII], but they only show that hospital charge for the clinic visit um on that [PII] date so we don't have any room and board charge now sometimes like I said, if it's observation like they just kept you to make sure everything was OK.
[AGENT][NEUTRAL] Um, it would need to have those charges of observation or, like I said, a room and board charge in order for us to consider that, um, hospital stay, it has to meet that 18 hours. So in other words that you have to be there at least 18 hours for it to be considered inpatient.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][POSITIVE] OK, got you, got you.
[AGENT][NEUTRAL] Yeah, do you know if you, do you know about how much time you were there approximately?
[CUSTOMER][NEUTRAL] I don't because we went in that evening and we uh we didn't sleep so I can't even tell you um it's so.
[AGENT][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] They give y'all something though, so you're saying that I need something with times on it.
[AGENT][NEUTRAL] Yeah, usually, um, usually you should be able to like, um, if there's no charges on the bill, which apparently there's not because they already provided you that um hospital itemized statement, perhaps you could obtain a um admit and discharge summary.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] And usually that it's an admission, it's called an admission and discharge summary and that kind of gives us a little bit um now it doesn't need to be um the whole medical record it just, it's called a usually they abbreviate it H&P but it's uh like a history and physical they do or an.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] Admit and discharge summary and what that will tell us is that you came into the hospital at such and such a time and that they needed to, you know, observe or keep you there just to check um to make sure that um you were obviously you were, it was preterm labor, correct?
[AGENT][NEUTRAL] Is the reason why you were there?
[CUSTOMER][NEGATIVE] Um, it was, yeah, it was, it's a previa, and so I was bleeding and that's why, that's why I got the other because uh two days later I got admitted and I didn't leave until I delivered in um April so.
[AGENT][NEUTRAL] OK.
[AGENT][NEGATIVE] Right. And I see that that was a long time. Yes, poor thing. Oh my.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] Yes, so I do see that we did pay that admission. Yes, so that's great for everybody's healthy.
[CUSTOMER][POSITIVE] Well we got it.
[CUSTOMER][NEUTRAL] Yes, we're everybody's healthy, we're home for little, but that's, that's all.
[AGENT][NEUTRAL] That
[AGENT][POSITIVE] Good.
[AGENT][POSITIVE] That's wonderful.
[CUSTOMER][NEUTRAL] So, OK, so you're, it's called admin and discharge paperwork.
[AGENT][NEUTRAL] Yes, it's called yep it's called admission and discharge summary admission and discharge summary.
[AGENT][NEUTRAL] And like I said, that will tell us, yes, admission and discharge summary, and that will like I said, it will tell us when you went in and then what you know proceeded to happen and then what when you were discharged and like I said, as long as it meets that 18 hours, we can go ahead and and and uh you know, make a determination as to whether the claim is eligible or not as long as it meets that 18 hours.
[CUSTOMER][NEUTRAL] And discharge
[CUSTOMER][POSITIVE] OK, OK, well, that's, that is perfect. I call them and see if they can get that sent over to your house.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and you can just go ahead and upload it through the portal once you receive it you won't need to file another claim or anything you'll just go ahead and upload that document just like you did with the um the documents you sent to us this last this latest document.
[CUSTOMER][POSITIVE] OK, OK, perfect, perfect, and that's you.
[AGENT][NEUTRAL] OK, did.
[AGENT][NEUTRAL] Did you have any other questions Miss [PII]?
[CUSTOMER][POSITIVE] No, ma'am, that is gonna be it for today. Thank you for your help.
[AGENT][POSITIVE] You're so welcome and you take care and congratulations again. I hope you have a great rest of your day. Thank you for calling APL.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][POSITIVE] Alright thank you bye bye.
[CUSTOMER][NEUTRAL] All right, bye-bye.