AccountId: 011433970860
ContactId: 462ef301-1774-4840-815b-d4a2632dc147
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 839710 ms
Total Talk Time (AGENT): 356696 ms
Total Talk Time (CUSTOMER): 325097 ms
Interruptions: 7
Overall Sentiment: AGENT=0.6, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/22/462ef301-1774-4840-815b-d4a2632dc147_20250522T14:36_UTC.wav
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[AGENT][POSITIVE] Thank you for calling American Public Life. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII] with Broker Resources. How are you doing?
[AGENT][POSITIVE] I'm good [PII] how are you?
[CUSTOMER][NEUTRAL] Right, I have someone from the brokerage office calling in regards to um group number 17886.
[CUSTOMER][NEUTRAL] And um I guess one of the insured um submitted a claim and it got declined and they're curious as to why it got declined in last year it was approved.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, uh, what is the.
[AGENT][NEUTRAL] Sorry
[CUSTOMER][POSITIVE] No, you're good.
[AGENT][NEUTRAL] Do you have the policy number for the insured?
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Yes, ma'am. It's gonna be 22.
[CUSTOMER][NEUTRAL] 81
[CUSTOMER][NEUTRAL] 87
[CUSTOMER][NEUTRAL] 7.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And uh do you
[AGENT][NEUTRAL] Did you get any information as far as who it's uh for?
[AGENT][NEUTRAL] Which, oh, it's OK, I see she's the only one on the policy.
[CUSTOMER][NEUTRAL] It's for [PII].
[AGENT][NEUTRAL] OK. Um,
[AGENT][NEUTRAL] You can send them over, uh, go ahead and send him over and I can get the rest of the information.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Perfect.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Perfect, thank you.
[AGENT][NEUTRAL] You're welcome, [PII].
[CUSTOMER][NEUTRAL] Ma'am, are you still there?
[CUSTOMER][POSITIVE] Yes, I'm here hi. OK perfect I have [PII] from our claims department and she'll be able to help you out with your questions OK? Perfect, perfect, thank you. Uh huh bye bye.
[AGENT][NEUTRAL] Hi, uh.
[CUSTOMER][NEUTRAL] Hi, hi, how are you?
[AGENT][POSITIVE] I'm good. How are you?
[CUSTOMER][NEGATIVE] Well, trying to get an answer for this client, and he's thinking she's driving me nuts.
[AGENT][NEUTRAL] OK, I can take a look at it for you. Could I get your name and a callback number?
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Sure. My name is [PII] Last name is [PII], [PII].
[AGENT][POSITIVE] OK, and a good call back number for you.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, thank you so much and uh what is the patient's name and date of birth and let me verify the account. I'm not sure if that was done before we.
[AGENT][NEUTRAL] She transferred you off.
[CUSTOMER][NEUTRAL] Sure. Uh her last name is [PII]. It's [PII] and her first name is [PII]
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, what else do you need? Sorry.
[AGENT][NEUTRAL] Uh, her date of birth.
[CUSTOMER][NEUTRAL] Oh, her date of birth, let me get it from here. Sorry about that.
[CUSTOMER][NEUTRAL] I didn't
[CUSTOMER][NEUTRAL] I didn't think I was gonna need that. Give me one second.
[CUSTOMER][POSITIVE] I should have it for you soon.
[AGENT][POSITIVE] OK, no problem.
[CUSTOMER][NEUTRAL] Her date of birth is
[CUSTOMER][NEUTRAL] [PII] and I'll tell you that here in just a minute.
[CUSTOMER][NEUTRAL] I apologize. The system makes me enter a code.
[AGENT][POSITIVE] No, no problem. Take your, yeah.
[CUSTOMER][NEUTRAL] To, to see uh dates of birth and social security numbers. OK. Um, it's [PII].
[AGENT][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] OK, thank you so much for verifying the account and so you are calling uh about a claim that was denied and I guess they feel the charges were once um paid I guess in the in the past we paid the charges.
[CUSTOMER][NEUTRAL] Two claims, yeah.
[CUSTOMER][NEUTRAL] Yeah, so the way she, yeah, the way she wore it was that every year she gets, um, this is a breast MRI every year, and I, I don't understand much of it, but she said uh with contract, one was a contract without contrast, something like that and um.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The one for [PII] [PII] is being denied, but the year prior, [PII] pays for it, which he was um.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, do you have the exact date?
[CUSTOMER][NEUTRAL] In [PII].
[AGENT][NEGATIVE] In October that was denied.
[CUSTOMER][NEUTRAL] Of [PII]. 0 yes, so uh there's two, so there is one for date of service of [PII].
[AGENT][NEUTRAL] OK, let me take a look at that one.
[CUSTOMER][NEUTRAL] And I have the claim number?
[AGENT][NEUTRAL] [PII] mm, OK, and what is the claim number? Oh OK.
[CUSTOMER][NEUTRAL] I mean 24, 24, 24.
[CUSTOMER][NEUTRAL] That's when, yeah, because he's not October yet. Sorry.
[AGENT][NEUTRAL] OK, so let's see this one. Let me pull the image and just compare them and see what's going on.
[CUSTOMER][NEUTRAL] And the other one is [PII].
[AGENT][NEUTRAL] OK. And the one for [PII] of, you said [PII]?
[CUSTOMER][NEUTRAL] Yes, uh, no, uh, no, no, no, no, no, no, no, I don't know when was the one on [PII]. I don't have that date. The two planes that are being denied is [PII] and [PII]. They're two days apart.
[AGENT][NEUTRAL] And what
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, let me
[AGENT][NEUTRAL] OK, so [PII].
[AGENT][NEUTRAL] And then, OK, so let me look at the diagnosis for October.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. So, the one for um [PII] was denied uh not due to sickness or injury. So it looks like these are routine services. Um, so it just shows a routine mammogram. The other does show family history of malignant cancer.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] We, if it was personal history of malignant cancer, you know, if she had had um malignant breast cancer in the past.
[AGENT][NEUTRAL] Then, um, you know, it would be considered under that. Uh, but with the way that it is being billed, uh, this would be considered routine. And so the policy would not cover routine services, only, uh, services due to injury or sickness.
[AGENT][NEUTRAL] And so that is why [PII] was denied.
[CUSTOMER][NEUTRAL] OK. OK.
[CUSTOMER][NEUTRAL] Yes, OK.
[AGENT][NEUTRAL] OK. And so [PII] was denied because uh what they're billing is an office visit and the policy does not cover physician office visits.
[CUSTOMER][NEUTRAL] So [PII] is the office visit. OK. Now let me, let me ask you, if, are you able to see if she had this procedure done in [PII] and if it was actually paid? because that's what she's saying, she says, I get it every year and now I'm like, oh goodness, I'm sorry.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Let me check.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I can try and check the to see if they're billing the exact same procedure code.
[CUSTOMER][NEUTRAL] Correct, because it could be that they built a different procedure code and that's what I'm thinking and that's what I was trying to explain.
[AGENT][NEUTRAL] Uh,
[AGENT][NEUTRAL] So when I looked through her, her history and put in the exact procedure,
[AGENT][NEUTRAL] It's not coming up. The only one that's coming up is this one here in [PII], but let me see if I can see anywhere in [PII], just some type of uh.
[AGENT][NEUTRAL] Mammogram, see if anything comes up. They may not have used the same code, but let me just look through her [PII] claims.
[AGENT][NEUTRAL] Let's see if I can find
[CUSTOMER][NEUTRAL] Yeah, I guess she calls a breast MRI, yeah, so.
[AGENT][NEUTRAL] OK, [PII] lab.
[AGENT][NEUTRAL] Uh.
[AGENT][NEUTRAL] Let me look at
[AGENT][NEUTRAL] Let's see some lab charges.
[AGENT][NEUTRAL] OK. I only see lab charges. I do see a facility charge. Um, let me go, let me pull the image and see if this was her MRI, her um breast MRI.
[AGENT][NEUTRAL] OK, so she did receive a breast MRI on [PII]. Um, it was performed at the hospital, but they did not, they billed, the way they billed the claim was under.
[AGENT][NEUTRAL] A sickness diagnosis. They did not use uh like a routine diagnosis. So that's the difference.
[AGENT][NEUTRAL] In the way that it was billed.
[AGENT][NEUTRAL] And we did make a payment on that one there.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Can I, um, are you able to tell me what is, um, what is that, uh, code that they built on [PII]?
[CUSTOMER][NEUTRAL] Or no? Like, are you allowed to do that?
[AGENT][NEUTRAL] Uh, I'm not able to reveal that information.
[CUSTOMER][NEUTRAL] Oh, OK, OK, no, I was just, I just, because at this point she's gonna have to call right? the provider's office and try to.
[AGENT][NEUTRAL] Yeah. She, so if she's using the same provider, she can, um, you know, speak with them and let them know, you know, OK, in October, uh, you know, [PII], you know, if you can look at how, you know, you submitted those charges, uh, versus, right, uh, the most recent. So that, that is the difference between the [PII], um.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] It was billed, yeah.
[AGENT][NEUTRAL] And, and then the one.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEGATIVE] So [PII] was an office visit, right? And [PII] is uh being denied because um the, the way it was built.
[AGENT][NEUTRAL] Now, the
[AGENT][NEUTRAL] OK. So the [PII] is just being billed as an office visit. So that, that one's not covered. The one I would think is in question is the [PII] because that is the actual breast, um,
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] MRI that was done, but um the diagnosis is a routine diagnosis and not a sickness diagnosis. So, you know, that, that's, yeah, and they can always submit a corrected bill.
[CUSTOMER][POSITIVE] Sounds good. Sounds good.
[CUSTOMER][NEUTRAL] So I um submit correct the bill.
[AGENT][NEUTRAL] If, if the diagnosis is not a correct diagnosis.
[CUSTOMER][NEUTRAL] I left the bill um.
[CUSTOMER][NEUTRAL] OK, and I just um submitted on the website, uh, the two that she did this year for, um, actually those were for a mammogram for 43 and 4:15 I submitted the EOI so they can be processed uh I filed the claim, so I think we'll just wait and see what happens with those.
[AGENT][NEUTRAL] OK, OK.
[CUSTOMER][POSITIVE] Fun times, fun, fun times, I tell you. Thank you so much.
[AGENT][NEUTRAL] Yeah
[AGENT][POSITIVE] You're welcome. Is there anything else I can help you with, [PII]?
[CUSTOMER][POSITIVE] No, no, no. I thank you, honestly.
[AGENT][POSITIVE] OK, you have a wonderful day. Thank you for calling APL.
[CUSTOMER][POSITIVE] You too, you too, thank you.
[AGENT][NEUTRAL] Bye-bye.
[CUSTOMER][NEUTRAL] All right, bye bye.