AccountId: 011433970860
ContactId: 2a42991e-9b3e-4cea-81bd-309df081c81d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 311299 ms
Total Talk Time (AGENT): 104366 ms
Total Talk Time (CUSTOMER): 102252 ms
Interruptions: 0
Overall Sentiment: AGENT=1.2, CUSTOMER=1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/01/2a42991e-9b3e-4cea-81bd-309df081c81d_20250401T14:42_UTC.wav
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[AGENT][POSITIVE] Good morning. Thanks for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII], this is [PII] from the care team and I've got a uh member on the line that has some additional uh questions about the claim status denial. Um, can I give you her information?
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Um, the policy number is 01579332.
[CUSTOMER][NEUTRAL] And I have verified all her information.
[AGENT][NEUTRAL] And can you verify the name of the insured?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And which policy uh which claim number is you referring to?
[CUSTOMER][NEUTRAL] Claim number is 3582495, so it looks like we received additional documentation from her just recently but it was denied again and I guess so I.
[CUSTOMER][NEUTRAL] I'm kind of confused with myself because
[CUSTOMER][NEUTRAL] The itemized bill says that she had a fall, so I guess I don't know do we have to have a specific diagnosis of fall or is is the itemized um description from the ER enough or?
[CUSTOMER][NEUTRAL] Because that's what she's questioning because they, it looks like they filed a claim with the diagnosis of diabetes, but.
[CUSTOMER][NEUTRAL] It says in the notes that she fell but like I said I don't know if that's that's what's holding up the.
[CUSTOMER][NEUTRAL] Claim is that diagnosis or if those notes aren't enough.
[AGENT][NEUTRAL] OK, let me just take a quick look here.
[CUSTOMER][NEUTRAL] Or if you can just tell me I can tell her so.
[AGENT][NEUTRAL] OK. Yeah, let me see exactly what we have because I believe it is that we need a diagnosis code from like the medical provider. So let me just take a look and see what we've received.
[CUSTOMER][POSITIVE] OK. OK, perfect. Thank you.
[AGENT][NEUTRAL] OK. So yeah, I see you have an itemized bill, but it does not have a diagnosis code on there. Let me see the other mail that we have.
[CUSTOMER][NEUTRAL] Oh, that was past medical history. I see. OK.
[AGENT][NEUTRAL] Yeah, so I'm seeing where it shows, yeah, that she had a fall, but it does not say like what she was diagnosed with, you know what I mean? Like what did she have a sprain, a fracture, you know, some type of like what, OK, she had a fall, but when you come in the emergency room like what did you diagnose her with for the treating condition? Um, so let me see. I'm looking through the physical exam.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] That makes sense. I didn't, yeah, I didn't see an ICD 10 listed, so, OK.
[AGENT][NEUTRAL] Yeah, so I would just say like uh like like I believe it's called a UBO4 like that document usually has uh 00 you usually have like a a diagnosis code on it.
[AGENT][NEUTRAL] Uh, from the provider.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, or, uh, like I said, she can also have, so I think it lists yeah an itemized diagnosis code or a super bill, any office notes or the admin and discharge summary, um, that has the actual diagnosis verified.
[AGENT][NEUTRAL] For her accident claim.
[CUSTOMER][POSITIVE] OK, OK, perfect.
[CUSTOMER][NEUTRAL] OK, that makes sense. I was just making sure that it's not enough that they write that she fell, right?
[AGENT][NEUTRAL] Well, right, I mean,
[CUSTOMER][NEUTRAL] They have to have that you have to we have to have the.
[CUSTOMER][NEUTRAL] OK, OK.
[AGENT][NEUTRAL] Yeah, cause like the, in the policy, it's going to be for a specific like, like accident condition. It's not just, oh, did, did you fall? OK, you fell, but what happened for you fall for you to get treatment? What did they treat you for?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK perfect OK alright I will let her know and thank you so much for the information.
[AGENT][POSITIVE] Uh, sure, yeah, you're welcome. Um, let me know if there's anything else you need.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] Alright thanks bye bye.