AccountId: 011433970860
ContactId: 49fdf6da-b042-4519-b064-18887c8a054f
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 465570 ms
Total Talk Time (AGENT): 253241 ms
Total Talk Time (CUSTOMER): 115343 ms
Interruptions: 1
Overall Sentiment: AGENT=1.2, CUSTOMER=-0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/17/49fdf6da-b042-4519-b064-18887c8a054f_20250117T15:48_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yes, [PII], this is [PII] and I got a letter back from y'all. I had filed a claim.
[CUSTOMER][NEGATIVE] Because I had to pay out of pocket uh.
[CUSTOMER][NEUTRAL] $546.09.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Out of my uh outpatient.
[AGENT][NEUTRAL] Yes, sir.
[CUSTOMER][NEGATIVE] And I file a claim for y'all to pay it back.
[CUSTOMER][NEUTRAL] And I just got a letter saying.
[CUSTOMER][NEUTRAL] That uh
[CUSTOMER][NEUTRAL] Y'all need some more information, but I sent y'all the bill I'm trying to figure out what you mean by that.
[AGENT][NEUTRAL] OK, Mr. [PII], so we've reviewed a claim and which was denied because we're needing additional information and you're wanting to see what else we need, is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Yes, I can help you with that. And what is your callback number, please?
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] 22.
[AGENT][NEUTRAL] Thank you. And your policy number, please?
[CUSTOMER][NEUTRAL] Policy number, hold on.
[CUSTOMER][NEUTRAL] Is the.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] 021.
[CUSTOMER][NEUTRAL] 92119.
[AGENT][POSITIVE] OK, Mr. [PII], thank you very much. Give me a couple of moments to get all of your information pulled up.
[AGENT][NEUTRAL] OK, and Mr. [PII], any information that I do provide for you today would be a verification of benefits and not a guarantee of payment. First off, I will need to verify several things for security. So what is your date of birth, please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you. Also your home mailing address?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] Thank you. The phone number we have for you is the same as the one that you provided for me, so that is your best contact number. Is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Thank you. And lastly, your email address?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] OK, thank you. So one moment.
[AGENT][NEUTRAL] OK, so Mr. [PII], I can see that I have spoken to you before as well. I thought you sounded familiar. OK, and so, um, while this other information is pulling up, I had emailed you your user guide to set up your portal in the online service center. Did you get that created and set up?
[CUSTOMER][NEUTRAL] No, I haven't been able to catch up with my daughter yet. Like I told you before, I'm not that good with computers, but once I catch up with her, we'll get it done.
[AGENT][NEUTRAL] Oh, OK. Right. OK.
[AGENT][NEUTRAL] OK, sure. So what is that, um, claim number that you're calling about, Mr. [PII]?
[CUSTOMER][NEUTRAL] It is
[CUSTOMER][NEUTRAL] 355-0970
[AGENT][NEUTRAL] OK, thank you. So, one moment. Let me get that pulled up.
[AGENT][NEUTRAL] OK, so in your, the, so you did receive your explanation of benefits in the mail. Is that correct, Mr. [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEGATIVE] OK, so there should be 2 pages to what you received or either the front and the back of just one page because the explanation or the benefit remarks as far as what the um denial reason was should be on there.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] But
[AGENT][NEUTRAL] But I can read you what it does state. It says in order to provide further consideration to this claim, please submit the following items.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Your explanation of benefits from your primary insurance carrier for this state of service.
[AGENT][NEUTRAL] And the second thing is the diagnosis for which the treatment was provided on this data service. And once we have received this information, we will resume processing this claim.
[CUSTOMER][NEUTRAL] OK, so I mean I gotta get with my primary insurance?
[AGENT][NEUTRAL] Yes, sir, we always, with this type of policy since it's a supplemental policy, as I explained to you before from your prime, with your prime, uh, let me try that again. Because this is a supplemental policy to your primary insurance, we will always have to have a copy of their explanation of benefits.
[AGENT][NEUTRAL] So that we can see the amounts that were applied to your deductible, co-pay or co-insurance for the data service that we're reviewing.
[AGENT][NEUTRAL] And then we have to have that itemized bill from your provider which includes the diag.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] So you gotta have the portion that they pay.
[AGENT][NEUTRAL] We have to have the the diagnosis for the treatment. That's the why they did whatever they did.
[CUSTOMER][NEUTRAL] Is what you're telling me?
[CUSTOMER][NEUTRAL] So you gotta have the diagnosis and the part that my primary insurance pays.
[AGENT][NEUTRAL] Yes, sir. And do you see those remarks that I just read to you on your explanation of benefits that you received?
[CUSTOMER][NEUTRAL] Yes, I see that on the back, but uh.
[AGENT][NEUTRAL] OK. So, yes, sir, that's the information. Mhm.
[CUSTOMER][NEUTRAL] I don't, OK, OK, I have one question though.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEGATIVE] I don't understand why y'all have to get the diagnostic.
[AGENT][NEUTRAL] Because that's part of the.
[CUSTOMER][NEGATIVE] That I don't understand.
[AGENT][NEUTRAL] Yes, sir. We have to have the reason, just like your, the primary insurance company does.
[CUSTOMER][NEUTRAL] Oh, you gotta have the reason why the test was done.
[AGENT][NEUTRAL] We have to have the
[AGENT][NEUTRAL] Correct, which is what the diagnosis means.
[AGENT][NEUTRAL] The diagnosis code for which this treatment was provided, that's the why they did whatever they did on that data service to you.
[CUSTOMER][NEUTRAL] Alright.
[AGENT][NEUTRAL] So your primary insurance company explanation of benefits for that data service and then your
[AGENT][NEUTRAL] diagnosis code for that data service. And once you have that, you can send that to us just like you did your other information and then we will continue reviewing your claim.
[CUSTOMER][POSITIVE] All right, thank you.
[AGENT][POSITIVE] Well, you are certainly very welcome. So is there anything else that I can help you with today?
[CUSTOMER][NEUTRAL] No, not at this time.
[AGENT][POSITIVE] OK, well then, thank you very much for calling Mr. [PII]. It was nice speaking with you again and I hope that you have a wonderful weekend.
[CUSTOMER][NEUTRAL] You too.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] Bye.
[CUSTOMER][NEUTRAL] Oh.