AccountId: 011433970860
ContactId: 2d6123e3-8a80-4874-8ee3-3963b3f6f6ef
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1120939 ms
Total Talk Time (AGENT): 324708 ms
Total Talk Time (CUSTOMER): 177939 ms
Interruptions: 0
Overall Sentiment: AGENT=0.5, CUSTOMER=-1.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/06/2d6123e3-8a80-4874-8ee3-3963b3f6f6ef_20250606T14:31_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. I'm sorry, good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] Yes, my name is [PII]. Um, I was calling to get some information about my son [PII]'s claim. It was processed and it came back at [PII], and I turned in the letter from the doctor stating that it was an accident, so I don't understand.
[AGENT][NEUTRAL] OK. Well, I can definitely look at the um claim for you and see what's going on. Um, may I have a good contact number in case we're disconnected and the policy number?
[CUSTOMER][NEUTRAL] Yes, [PII].
[CUSTOMER][NEUTRAL] And let me get my policy number, just a second.
[AGENT][POSITIVE] OK. Take your time.
[CUSTOMER][NEUTRAL] 244-622-2.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] All right, and I just need you to verify your date of birth, your mailing and email address on file.
[CUSTOMER][NEUTRAL] Yes, [PII] address [PII] email is [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And you said this is for [PII], right?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] And do you mind if I place you on just a brief hold while I look at the claim, and this is the most recent one here from [PII], right?
[CUSTOMER][POSITIVE] Yes, I don't mind.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right, hold on one moment.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Alright
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] So first, let's see what it was denied for DA.
[AGENT][NEUTRAL] And what was received just in case.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Hello, [PII].
[CUSTOMER][NEUTRAL] Yes, I'm here.
[AGENT][POSITIVE] Thank you so much for holding. I apologize for the wait. So it was denied, but it was denied requesting additional information. So we got the letter from Doctor [PII], um, but they, they're asking for
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] So it needs to be like on documentation like if there's office notes showing what happened, like we know he says that it's an overuse injury, exacerbated with the basketball, but for us to prove medical necessity if we're audited, we would need more, you know, like an office note, what happened, what was the treatment. We just, that's all they're asking for, just um.
[CUSTOMER][NEUTRAL] I had, I had already checked all of it. He was, he had physical therapy and everything.
[AGENT][NEUTRAL] Oh, it was sent in with this claim or something previously?
[CUSTOMER][NEUTRAL] No with this claim. I sent in a lot of stuff.
[AGENT][NEUTRAL] Well, hold on now.
[CUSTOMER][NEUTRAL] He did a total of what? 10 weeks of physical therapy. I mean, he did all that.
[AGENT][NEUTRAL] So who sent this in because literally it's only all the broker, hold on one second. The reason I'm asking because I pulled up the documents, but it's only literally is one page and it was just a letter from the doctor, so that's why they're asking for all that stuff.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Because, you know, before, when the, the when the um claim was first opened, I sent in a lot of documents.
[AGENT][NEUTRAL] Wait, so is there
[AGENT][NEUTRAL] You want me to look at some of the prior?
[CUSTOMER][NEUTRAL] There's additional documents.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, let me look at like what what all has come in for him because from the, from just this claim here in May when I pulled up because I was like, well, let me see what was sent in, but it's just this, it's a cover page and then the letter from Doctor [PII], that's it.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Yeah, that was just what I sent them from last week, but when the first when the case was first opened the claim, I sent them stuff from his primary doctor. I sent them stuff from his, the, uh, the orthopedic doctor and from the physical therapist. I mean, it, it was a lot to have to go with the, yeah, cause he was in really bad shape. He had a lot of stuff wrong.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Well, let me
[AGENT][NEUTRAL] OK, let me um look at the other claims and then I'll just have to let claims know that the documentation for the one that they're process or, you know, just worked on has been sent previously, so they can go through the old stuff. Do you mind if I place you on just another brief hold? I there looks like two other claims that came in.
[CUSTOMER][POSITIVE] Yeah, I don't mind. Yes.
[AGENT][NEUTRAL] OK. Hold on one second.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Alright, so let's start with 326.
[AGENT][NEUTRAL] Oh wait, wait, wait.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEGATIVE] I don't know what they're looking for.
[AGENT][POSITIVE] Supporting.
[AGENT][NEUTRAL] Documentation to evidence of an accident.
[AGENT][NEUTRAL] Uh, probably the supporting documentation to evidence that accident and when it occurred, supporting documentation.
[AGENT][NEUTRAL] They got the physical therapy notes.
[AGENT][NEUTRAL] She, we paid for it. Wait a minute.
[AGENT][NEUTRAL] I'm about to get her to clean.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] I don't know how much detail we need.
[AGENT][NEUTRAL] Well, then let me look on the 2nd 1 that we paid and see what, what that looks like. Cause we paid that one with that.
[AGENT][NEUTRAL] Routine physical.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Hello [PII].
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] All right, thank you so much for holding again. I apologize for that wait. So I did go through the other um claims. So that very first claim that you sent in, I see the documents like with the physical therapy notes and everything. Um, I'm gonna reach out to the claims examiners and see if I can get someone on the line with us or with I'm gonna connect you with them because I don't, I'm not quite sure what else they're looking for and I don't, I don't want to advise on anything and it's wrong.
[CUSTOMER][NEUTRAL] It's OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um, because I saw it.
[CUSTOMER][NEUTRAL] Cause I can't get stuff, so I tried to spend as much as I could.
[AGENT][NEUTRAL] Right, and I was asking, it just says supporting documentation, it could be office notes, admission papers, diagnostic testing, so I saw the uh physical therapy notes, um, well, it was a whole bunch of things there was a lot of stuff.
[CUSTOMER][NEUTRAL] I mean, he had X-rays, he had X-rays and everything, so I don't understand like.
[AGENT][NEUTRAL] Yeah, so I'm gonna get a claims rep on the line because I to provide further what they're exactly what they're looking for because they're processing the claim.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, but before I do that, was there anything else I could assist you with today?
[CUSTOMER][POSITIVE] No, ma'am. That's it. Thank you so much.
[AGENT][NEUTRAL] You're very welcome. Well, thanks for calling APL and hold on one moment, OK?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][POSITIVE] Good morning. Thanks for calling APO. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hey, [PII], this is [PII] on the care team. How are you doing?
[CUSTOMER][POSITIVE] I'm good how are you?
[AGENT][NEUTRAL] I'm doing good. Um, I have an insured mother on the other line. She's trying to figure out what we're looking for to process this claim. Um, can you look at this with me, or, oh, I'm gonna have to transfer her because I don't know what else to tell her, but, uh.
[CUSTOMER][NEUTRAL] OK, what's your policy number?
[AGENT][NEUTRAL] It's 244-622-2.
[AGENT][NEUTRAL] It's for part two.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] See, we denied it.
[AGENT][NEUTRAL] And it's the last claim we processed and the first claim we processed.
[CUSTOMER][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] OK, you say we need evidence of the documented evidence of COVID document.
[CUSTOMER][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] So when I pulled up the last claim that we processed, all we received was like it's just a letter from the doctor.
[AGENT][NEUTRAL] So then I told her, you know, I, after I told her what I saw, I gave, I told her the denial reason and what we need, and then she said, well, I already sent all that in. So I looked at the first claim we processed.
[AGENT][NEUTRAL] And I mean on the claim form, it does give a description and she has like physical therapy notes and stuff. Is there a particular type of notes we're looking for? I didn't know what else to tell her.
[CUSTOMER][NEUTRAL] Give me one second, I'm trying to pull it up my own pace. It's going slow.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, mine is too.
[AGENT][NEUTRAL] Very.
[CUSTOMER][NEUTRAL] I found that crazy.
[CUSTOMER][NEUTRAL] Mm, [PII] and I can see my phone over you and with that basketball, da da da.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] One second, [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEGATIVE] Crap
[CUSTOMER][NEUTRAL] OK, nothing there. All right, send her on over. Let's see what we got here.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right, hold on one moment. Thank you.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Hello, [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] All right, thank you so much for holding. I have [PII] on the line and she'll be assisting you further, OK?
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][POSITIVE] Good morning thanks for calling