AccountId: 011433970860
ContactId: 406ba009-5f13-44e1-a840-a7745e354304
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 648530 ms
Total Talk Time (AGENT): 391470 ms
Total Talk Time (CUSTOMER): 202314 ms
Interruptions: 2
Overall Sentiment: AGENT=0.2, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/19/406ba009-5f13-44e1-a840-a7745e354304_20250219T14:11_UTC.wav
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[AGENT][NEUTRAL] Good morning. Thank you for calling APL. This is [PII] speaking. How can I help you?
[CUSTOMER][NEUTRAL] Hey, [PII], it's [PII]. Good morning.
[AGENT][NEUTRAL] Hi [PII], how are you?
[CUSTOMER][NEUTRAL] Oh, I'm OK.
[CUSTOMER][NEUTRAL] It's Wednesday. Glad of that, but I'm OK. So I have a, uh, an insured on the line who have gone over her claim. Her husband, it's for her husband. She's the insured, but it's the most recently received and processed claim for her husband. Um, the policy number, [PII] is 254.
[CUSTOMER][NEUTRAL] 5851 and again the claim is for part two.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And it's claim number 356-547-3.
[CUSTOMER][NEUTRAL] And it states on one of the remarks, again, I went over both of them, but the medical records requested, but I don't see a note on this policy regarding that.
[CUSTOMER][NEUTRAL] So she's wanting to verify if we've requested them or if that's something that she's supposed to do and I can't answer that she's upset.
[AGENT][NEUTRAL] OK, 6 64 73, right?
[CUSTOMER][NEUTRAL] Yes, uh huh, yes.
[AGENT][NEUTRAL] Sometimes it could be in the EOB andT notes um.
[AGENT][NEUTRAL] You know where they add.
[AGENT][NEUTRAL] Let me see if they included it.
[AGENT][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Oh, EOB and T, is that what you said?
[AGENT][NEUTRAL] Yeah, if, if there's something sometimes they add notes in the EOBNT screen if there's uh.
[CUSTOMER][NEUTRAL] And on that screen, do mm.
[CUSTOMER][NEUTRAL] OK, do I have to go to that from [PII]? Well, I can't sometimes I don't know, maybe I'm not doing it right, so you go to [PII] and then go to EOBNT.
[AGENT][NEUTRAL] I'm looking now.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um, I'm not sure how to access it that way. I just know it from, um, and there's, I don't see any notes, uh, I looked in, I'm looking in there now, usually it's from that claim screen and you wouldn't know that if you're not processing claims, so.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So it looks like we're asking for evidence of an accident, so, um.
[CUSTOMER][NEUTRAL] Mhm. And then the second remark state medical records request.
[AGENT][NEUTRAL] Usually that would mean that we reached out as long as we had our authorization and it looks like we did um but you're right I don't see any.
[AGENT][NEUTRAL] Indication that we.
[AGENT][NEGATIVE] And there wasn't anything in the notes.
[CUSTOMER][NEUTRAL] I didn't see anything.
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] So I'm looking at it now so.
[CUSTOMER][NEUTRAL] And just so you know [PII], um, the phone number for Miss [PII] is the same as the one that's in Lion.
[AGENT][NEUTRAL] OK, and is that that one listed there that's [PII].
[CUSTOMER][NEUTRAL] Yes, it is the uh-huh [PII]. Mhm.
[AGENT][NEUTRAL] And she's all been verified correct?
[CUSTOMER][NEUTRAL] She has fully been verified, yes, and she's already on the list, so we didn't talk about that.
[AGENT][NEUTRAL] Yeah I don't see where the notes were requested either, but usually when we use when we use that code, that means that we're reaching out for medical records so um.
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] I'm looking over the documents. If you wanna go ahead and transfer, and I'll do my best to assist her. It looks like we don't have an accidental diagnosis code, so that's why we're reaching out, um, because it is an accident policy. It does require accidental bodily injury. So, um, that's what we have to verify.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right. And I did read, like I said, I did read that remark, but she's needing to verify who's supposed to be getting these records and I just
[CUSTOMER][NEUTRAL] I don't know what to tell her because she's.
[CUSTOMER][NEGATIVE] You know, she got, she was upset when she got that, you know.
[AGENT][NEUTRAL] Right.
[AGENT][POSITIVE] OK, well I'll do my best to assist her.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] I know you will, you always do, and I always appreciate you. OK, [PII]. Well, thank you so much. Are you ready for this meals?
[AGENT][NEUTRAL] I am mhm.
[CUSTOMER][POSITIVE] OK. Thank you. Have a great day if I don't talk to you again.
[AGENT][POSITIVE] You too [PII] thank you.
[CUSTOMER][POSITIVE] Thank you. Bye-bye.
[AGENT][NEUTRAL] Bye.
[AGENT][NEUTRAL] Hello Ms. [PII].
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][POSITIVE] Hi, good morning. My name is [PII]. I'm in the claims department, um, and [PII] had, um, I'm doing well, thank you. How are you?
[CUSTOMER][NEUTRAL] Oh right.
[CUSTOMER][NEUTRAL] I'm OK.
[AGENT][NEUTRAL] OK, so I understand we have some questions about the claim for uh your uh your uh.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Your spouse, um, and it looks like um what happened is we received that documentation for, um, looks like a data service of [PII] and we received that information from uh that you uploaded for the claim. however, it looks like we're needing more information to be able to verify this was an accident or an accidental bodily injury.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Cause what the codes read on the, the form, uh on the uh statement that was received from the orthopedic doctor, it just shows the diagnosis codes being pain. Um, so we're needing to verify that this is an accidental bodily injury.
[CUSTOMER][NEUTRAL] No, he
[CUSTOMER][NEUTRAL] He has to have a whole, he has to have a surgery. He, he fell out the bed.
[CUSTOMER][NEUTRAL] Cracked his knee, stayed in pain, but has to have a surgery on that knee.
[AGENT][NEUTRAL] Uh huh.
[CUSTOMER][NEUTRAL] And so I sent you more documentation yesterday with some codes and the date of his surgery.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Now let me just take a look here. So what, but the coding, unfortunately the coding that was provided thus far just shows us that it is uh 125. I'm looking up the code now just bear with me for just a moment.
[CUSTOMER][NEUTRAL] OK, sure.
[AGENT][NEUTRAL] So, um, under the accident policy, it does require that accidental bodily injury diagnosis, meaning it can't be like pain, um, or, or it can't just be, um, that ill what we consider that illness diagnosis. It has to be a bodily injury such as a, a strain, a sprain, a contusion, a fracture or anything like that. So that shows us that it's an accidental bodily injury.
[AGENT][NEUTRAL] But that's why we're reaching out for additional information we requested, um, and, and that's what that code that is on the claim that you received the explanation of benefits for we're, you know, we ver we stated that we just needed to verify that it was, um, uh, let's see how it reads it reads that we need the evidence of a covered accident receipt because we're receipt.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Well, how, if, if we didn't, if we didn't go to the, we didn't call the police, so we, I mean he fell out the bed. So, so we have an X-ray. We have, um, my, my husband has to have surgery on the [PII]. I sent that information in. You don't have surgery just for pain.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] No, I understand that, but what we're trying to verify is that this, this visit itself because like I said, it, the, the coding that they used at the orthopedic office just says pain in your knee. So we're needing to verify that it was an accident.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] It was just
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] Bodily injury like you said it's it we need more evidence of uh that being an accident of bodily injury so that's why we're reaching out for additional information to be able to verify that. Now you said you sent, you sent in information um did you send it through the mail or the fax or did you upload it?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK. Mm.
[CUSTOMER][NEUTRAL] No, I uploaded it yes. I uploaded it yesterday.
[AGENT][NEUTRAL] OK, because I don't see it as of yet.
[AGENT][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Well, we see the [PII], but that was just the um orthopedic statement that uh that we received and that's when we process the claim and we are stating we need more information and like I said, so we're gonna reach out and just get that.
[AGENT][NEUTRAL] Information and let it be an X-ray. It could be office notes we just have to be able to verify that it was an accident related to an accident being that this is an accident policy. It does require we have to meet that, uh, we have to meet that verification and, and we have to have it documented.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so who do, I mean, OK, so you need the physician statement, that's what you're saying?
[AGENT][NEUTRAL] Well, it, it, it can be a physician statement, but like I said, we're reaching out to verify that and like I said, that's what that code tells us, um, that was printed on the explanation of benefits that tells us that um there's if there's evidence if there is we're needing uh additional information for further consideration is we will need support supporting documentation of evidence that it was an accident and when it occurred so.
[AGENT][NEUTRAL] 9.
[AGENT][NEUTRAL] Uh uh admission discharge summary and or diagnostic testing results. So if we could have, you know, that X-ray or those office notes from the orthopedic that states that it was in fact, um, an accidental bodily injury and we understand that he's like you said, he's going to be, uh, he's scheduled for surgery, so that information that the orthopedic can provide us will be able to verify that information.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK, alright, well I'll just get have them fill out a physician statement.
[AGENT][NEUTRAL] OK and like I said, in the meantime we are reaching out for those uh office, you know, information from the orthopedic um asking for that verification as well.
[CUSTOMER][NEUTRAL] So y'all reached out to him?
[AGENT][NEUTRAL] That's what the um information that I'm seeing, yes, mhm.
[CUSTOMER][NEUTRAL] OK.