AccountId: 011433970860
ContactId: 55d821c1-e902-4cd0-966d-641d9118de96
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 305690 ms
Total Talk Time (AGENT): 114886 ms
Total Talk Time (CUSTOMER): 143925 ms
Interruptions: 0
Overall Sentiment: AGENT=0.2, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/15/55d821c1-e902-4cd0-966d-641d9118de96_20250415T18:29_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Oh, good afternoon. Um, my name is [PII], and I have a policy with you and I have a question about a claim that I've just received an EOB for, but I might need to speak to your billing department, but I can, um, what would you like from me first?
[AGENT][NEUTRAL] I'm sure [PII], I can assist you with claim status. Um first, could I get a good callback number just in case we're disconnected?
[CUSTOMER][NEUTRAL] Yeah, so I'm on my um home, home phone number. It's [PII] is a direct line.
[AGENT][NEUTRAL] Thank you. Now, I need your policy number, please.
[CUSTOMER][NEUTRAL] 02187247. M as in Mary, L as in Larry, number 8.
[AGENT][NEUTRAL] Thank you, [PII], and please verify your first and last name and your date of birth.
[CUSTOMER][NEUTRAL] [PII], [PII].
[AGENT][NEUTRAL] OK. And now, please verify your mailing address and your email address.
[CUSTOMER][NEUTRAL] [PII]. And my email is my first name, [PII].
[AGENT][NEUTRAL] OK, thank you. And um what's the claim number for the claim you're calling about?
[CUSTOMER][NEUTRAL] 358-624-7
[AGENT][NEUTRAL] OK. Yes, ma'am. I'm showing that that claim was for an office visit and under your policy, office visits are not covered. Um, services provided in the office is covered. Anything that goes towards the co-insurance or the deductible after your primary insurance processes the claim, but the co-pay for the office visit is not covered.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Well, it went to, on the EOB it shows that the whole thing went towards my deductible. Um, there were two line items. And I called yesterday about a different claim and spoke to somebody in your billing department. Um, this says it was to do with breast cancer. Um, he's a plastic surgeon that he had to fix me. Um, and she said that I have a rider on my policy that anything to do with the breast or cancer um is covered at 100%.
[CUSTOMER][NEUTRAL] I know it doesn't say anything on here. It just says [PII].
[AGENT][NEUTRAL] Right. And we go by the diagnosis code and actually the diagnosis code on these claims are not, on this claim is not cancer-related. So that's why I denied, but if it is, the provider can refile the claim and um send in a corrected claim with the um correct diagnosis code and the claim could be reprocessed.
[CUSTOMER][NEUTRAL] Bye.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEGATIVE] This doctor's office is a nightmare.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Can I ask you what diagnosis code that uh that it was submitted originally, and the ICD 10?
[AGENT][NEUTRAL] Um, yes, ma'am. Let's see.
[CUSTOMER][POSITIVE] Do you see that, please? Thank you.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. There's a diagnosis code for complication um for the breast implant.
[AGENT][NEUTRAL] And then there's another diagnosis code.
[CUSTOMER][NEUTRAL] Do you happen to have the actual code, the ICD 10 code, not just the description?
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] Yes, ma'am. The code is T like Tom.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] 85
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 49 X like X-ray, A like apple.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then the other code is N like Nancy.
[AGENT][NEUTRAL] 65.1.
[CUSTOMER][NEUTRAL] Just 1, not 01, just 1.
[AGENT][NEUTRAL] Right, just one.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] So, um, I'll look those codes up. So because you didn't put the, it was originally cancer related, it was just complication, um, it didn't, even though the primary.
[CUSTOMER][NEGATIVE] It shows under the deductible.
[CUSTOMER][NEGATIVE] And it's obviously originally, I did not have these done purposely. It was because of breast cancer. Um.
[CUSTOMER][NEUTRAL] Because I, when I called yesterday, the lady was sending a claim back to be resubmitted.
[CUSTOMER][NEUTRAL] So I can't have that done. I have to go back to the doctor and get the codes amended.
[AGENT][NEUTRAL] Right, and the doctor can resubmit the claim or correct the claim with the correct diagnosis codes that are cancer-related and the claim can be reprocessed. Yes, ma'am.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK. I know they have a new billing lady. I'll see if I can contact her and um see if you can help me. OK, well, thank you very much for your time.
[AGENT][NEUTRAL] OK. Is there anything else I can assist you with?
[CUSTOMER][POSITIVE] Nope, that's it for today. Thank you.
[AGENT][POSITIVE] Mhm. Thank you again, [PII], for calling APL. You have a great rest of your day. Mm bye.
[CUSTOMER][POSITIVE] Thank you. Bye-bye.
[AGENT][NEUTRAL] Bye.