AccountId: 011433970860
ContactId: 2ec97df2-ed7d-44bd-ac36-99783d172abf
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 358160 ms
Total Talk Time (AGENT): 220949 ms
Total Talk Time (CUSTOMER): 117315 ms
Interruptions: 4
Overall Sentiment: AGENT=-0.1, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/14/2ec97df2-ed7d-44bd-ac36-99783d172abf_20250214T18:16_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII]. How are you?
[AGENT][NEUTRAL] Fine, how are you?
[CUSTOMER][POSITIVE] Good. Happy [PII].
[AGENT][POSITIVE] Thank you to you too.
[CUSTOMER][NEUTRAL] I have an insured on the phone. Let me give you the policy number.
[CUSTOMER][NEUTRAL] It's 228-3755 [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I read the remark code to him and specifically, what does that mean? He said he injured his back. It's the 356-3690.
[AGENT][NEUTRAL] Which claim is it?
[AGENT][NEUTRAL] OK, let me see what we got here.
[CUSTOMER][NEUTRAL] And he just said he injured his back at work.
[CUSTOMER][NEUTRAL] And that's a lot of words in that that remark.
[AGENT][NEUTRAL] So the, this particular coverage only covers if it's due to
[AGENT][NEUTRAL] Um, bodily injury. So let me see what he's sending cause the diagnosis code is not saying it was any body, bodily injury. So let me see what we got.
[CUSTOMER][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] Let's see here if it comes up.
[CUSTOMER][NEUTRAL] Like, like, should that be like an S code?
[AGENT][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Not necessarily? OK.
[AGENT][NEUTRAL] Yeah, for example, not necessarily, but for example, yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Is it OK.
[AGENT][NEGATIVE] Well, that document is not gonna let me try another way.
[AGENT][NEUTRAL] So wait a minute, have this claim, I'm showing this claim is in audit. It is, so this hasn't been issued yet.
[AGENT][NEUTRAL] We haven't even reviewed it yet.
[CUSTOMER][NEUTRAL] But look at, look at lion.
[AGENT][NEUTRAL] It's an audit. This was just processed today. It's an audit review by the examiner.
[CUSTOMER][NEUTRAL] OK, so if I went to see LPAY, would I see that?
[AGENT][NEUTRAL] So.
[AGENT][NEUTRAL] No, cause it's a denial, so we haven't even released this yet. Uh, yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me see what else we got because it's under review.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh let me see what all we got though.
[AGENT][NEUTRAL] Did you already tell him that denial? Oh.
[CUSTOMER][NEUTRAL] I did, I did.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] So I'm just gonna back that up and say it's being reviewed.
[AGENT][NEUTRAL] Uh,
[AGENT][NEUTRAL] Yeah, it is cause it has not been released from audit yet, but yeah, looking.
[CUSTOMER][NEUTRAL] How do, how do we know that?
[AGENT][NEUTRAL] Well, only because I would advise if you see that same process date as today's date.
[CUSTOMER][NEUTRAL] Like on our end.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I would just tell, I usually advise you to tell them that it's it's in review, because especially if it's an audit, but you don't know that it's an audit on your end, but if you see that today's date, I would just let, I usually let them know it's in final review.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Cause we don't know if we can.
[CUSTOMER][NEUTRAL] Do we not use that internal pin that 072 code that IA 072 anymore?
[AGENT][NEUTRAL] Um, that's only if you're waiting on something to process the claim.
[CUSTOMER][NEUTRAL] Seem like there was a pin code if it was being uh reviewed by.
[CUSTOMER][NEUTRAL] I know it's an internal code, but I don't remember what it was.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] No, we don't, the claim isn't pending when it's an audit.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Alright, because we don't have a, we wouldn't know that it's an audit, I guess that's what I'm saying.
[AGENT][NEUTRAL] Mm mm, no. So I'm saying that if you ever see a claim with this it's processed the same status date, I would advise you to tell them that it's in, it's in final processing. I wouldn't give no benefits amounts, I wouldn't give anything regarding the denial either.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] OK, so the process date is today.
[AGENT][NEUTRAL] Until that EOB is actually printed.
[CUSTOMER][NEUTRAL] OK, OK, so if I looked at the stat date and it's today, am I automatically assume that it's an audit?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] No, not necessarily, but I still was test and find a review because even if it's not an audit, if the exam to go back and feel like they should have added something differently, they can by the end of the day cause you'll be having printed.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] They can still make changes to that entire claim today.
[CUSTOMER][NEUTRAL] Now how would we know that, Ms. [PII]?
[AGENT][NEGATIVE] Well, EOBs don't print. The actual EOB don't print till tonight. Any claim. Yeah. And even, even on dollar amounts, even when you don't see that the dollar amount has not been released. I mean, even when you see a dollar amount, it's still showing like a 11 $1900 I still wouldn't tell them that this is a benefit amount you're gonna get because that EOB haven't even printed and somebody can still go back in there and make changes to that dollar amount by the end of the day.
[CUSTOMER][NEUTRAL] Uh, the evening, yeah. Yeah.
[CUSTOMER][NEUTRAL] Ah
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So, yeah.
[AGENT][NEUTRAL] But it looks like, OK, we got the claim form. Let me see what else we got here.
[AGENT][NEUTRAL] To see what else he's sending because so far I'm just seeing the claim form.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yea[PII], that diagnosis code is only saying he has back pain.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah. Um, I, since you have already told him that remark code, I would just advise him based off the information, it's [PII]t only indicating that, you know, you have back pain.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] But the policy only covers if there's any um bodily injury and that information provided does not indicate that bodily injury occurred.
[CUSTOMER][NEUTRAL] Mhm. Oh Lord, he is, he's on 200, OK?
[AGENT][NEUTRAL] Is it, OK, well, tell them that it's, you can tell them that it's still in its currently in review though cause it is, cause it hadn't been released from audit.
[CUSTOMER][NEUTRAL] I'll do that. I, I'll do.
[CUSTOMER][NEUTRAL] Yeah, he is on 200.
[AGENT][NEUTRAL] Yeah, it had been released.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, I'll do that. All right, bye bye.
[AGENT][NEUTRAL] All right. OK. Bye.