AccountId: 011433970860
ContactId: 43b871b3-4665-46aa-9c98-e0485a2227ec
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 512710 ms
Total Talk Time (AGENT): 137410 ms
Total Talk Time (CUSTOMER): 248290 ms
Interruptions: 1
Overall Sentiment: AGENT=0.7, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/27/43b871b3-4665-46aa-9c98-e0485a2227ec_20250527T18:59_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII] Doing calling from Ameribank Group Benefits. Um, we're a broker's office. I'm calling on behalf of Wagner County, and I wanted to check and their, uh, account number is [PII].
[CUSTOMER][NEUTRAL] And I was gonna check on a claim.
[CUSTOMER][NEUTRAL] For an employee.
[AGENT][NEUTRAL] OK. Do you have the policy number for the employee?
[CUSTOMER][NEUTRAL] I do 262-1965. Last name is [PII] first name [PII].
[AGENT][NEUTRAL] OK, and then do you have a good callback number, [PII]?
[CUSTOMER][NEUTRAL] I do. It's [PII].
[AGENT][NEUTRAL] And what is your email address?
[CUSTOMER][NEUTRAL] It is [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And do you have the date of birth of that member?
[CUSTOMER][NEUTRAL] I'll see if it's on here.
[CUSTOMER][NEUTRAL] Uh it's not on our, on the portal so I'm gonna have to go back in their file. Give me just a second.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Sorry, my computer is moving at a snail's pace.
[AGENT][POSITIVE] Oh, you're totally fine. Ours was, everybody's this morning was pretty, pretty slow.
[CUSTOMER][NEUTRAL] Oh yeah.
[CUSTOMER][NEUTRAL] Um, [PII].
[AGENT][NEUTRAL] OK, thank you so much. Uh, let's see what was this for? Um, it looks like I only have one claim on file for her. It was from [PII].
[CUSTOMER][POSITIVE] Yes, yes. Yes.
[AGENT][NEUTRAL] So it looks like
[AGENT][NEUTRAL] Uh, let's see, so there was a submittal for an office visit, um, which was non-covered under the policy, but there was a second charge.
[AGENT][NEUTRAL] Um, for for 8744.
[AGENT][NEUTRAL] Um, let's see here.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I'm looking
[AGENT][NEUTRAL] Looks like we need a more of an itemization, something that shows like the diagnosis code.
[AGENT][NEUTRAL] Um, what procedure?
[CUSTOMER][NEUTRAL] OK, because, uh, what I, the paperwork she gave me, um, and I uploaded, I think this whenever this was 2 weeks ago it was before I went on vacation, so, um, my brain is not back there yet, um.
[CUSTOMER][NEUTRAL] So we called to get the diagnosis code we were told there was only one and I put it on that front page.
[AGENT][NEUTRAL] Well, it has to, so it can't be entered by anybody but the medical provider.
[AGENT][NEUTRAL] Um, so it has to, we have to have documentation.
[CUSTOMER][NEUTRAL] The what it what.
[CUSTOMER][NEUTRAL] What can't be entered?
[AGENT][NEUTRAL] Diagnosis code, so.
[CUSTOMER][NEUTRAL] The diagnosis
[AGENT][NEUTRAL] Right, so it has to be from.
[CUSTOMER][NEUTRAL] Well, we've.
[CUSTOMER][NEUTRAL] We've never gotten it like from the actual, well, I say we get it from the actual doctor. They don't ever give us anything with anything printed because um
[CUSTOMER][NEGATIVE] It's so difficult to actually get.
[CUSTOMER][NEUTRAL] Um, you would be surprised how difficult they make.
[CUSTOMER][NEUTRAL] Calling to get on the members to get their get their information so um.
[CUSTOMER][NEUTRAL] We actually got it from Blue Cross.
[CUSTOMER][NEUTRAL] Directly.
[AGENT][NEUTRAL] Is there any way she can log into her portal and maybe print something from that?
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Well, they, they don't, they don't put the diagnosis codes on their paperwork. They put billing codes which members get very confused about and so, um, not only will most of these like providers not take the take APL and we have it through us, our own company that handles all the benefits um.
[CUSTOMER][NEUTRAL] But yeah they won't take the card so the members are left to do it themselves but um any claim that we've uploaded before we just.
[CUSTOMER][NEUTRAL] Type the diagnosis code on there.
[AGENT][NEUTRAL] Well, I know that, I mean, uh, from I mean from our standpoint, we, I mean anybody could type anything, so that's why we have to have actual documentation.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] You know, that something.
[CUSTOMER][NEUTRAL] OK, because we're always told they just needed the the diagnosis code and so, but I know that um things have gotten.
[CUSTOMER][NEGATIVE] Like, I can pull somebody else up where we did it, and the claim was paid and everything else. No one ever said, like I said, trying to go back and get it from the actual cause they never speak to the doctor, they call the office and um we, I actually had somebody um
[CUSTOMER][NEUTRAL] That had some it was had to do with endometriosis and there were several and they actually told her there were too many to to start listing them all.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEGATIVE] And so then we had to go another route and and and and for her to even get her like to be reimbursed um they're very they're just very difficult to.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um, another option would be.
[CUSTOMER][NEUTRAL] So I don't
[AGENT][NEUTRAL] They would provide the HIPA 1500, so that's just, that's just simply one page and that's the claim form that they submit to.
[AGENT][NEUTRAL] Blue Cross Blue Shield.
[AGENT][NEUTRAL] Um, that could be another option.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] OK, looking back on this, I also didn't see like an 87.
[CUSTOMER][NEUTRAL] Dollar oh there it is cost of service 8744.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] But that's it's they're just so you're saying that there's since there was no code with it that it won't be paid.
[AGENT][NEUTRAL] Right, because I've, I've actually had these before with just various members, um, and spoke to our claims department and I don't know if they've just tightened up the processes, um, but they're, they're.
[CUSTOMER][NEUTRAL] Yeah because I mean yeah I'm gonna let [PII] know this because I didn't we've never run into this before they just said as long as you submit something else saying what the codes are you know with it that's what they need along with the policy then.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK, well I'll let him know and he can let.
[CUSTOMER][NEUTRAL] And if he needs to call somebody but because yeah I don't know if something changed or what, but this is how we've been doing it.
[CUSTOMER][NEUTRAL] For at least the last 4 years.
[AGENT][NEUTRAL] Uh, you might talk to broker resources too and see if they have any insight, but I know like I said, I have run across this uh quite a few times and that's, that's the explanation that I'm getting from the claims team is that they're not able to accept anything that's like typed in or whatever it has to be actual documentation so from the healthcare provider.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK all right thank you I appreciate it.
[AGENT][POSITIVE] OK, thanks for calling APL. Have a good day.