AccountId: 011433970860
ContactId: 564fad0c-e7e3-4243-aea7-b0f312814238
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1283560 ms
Total Talk Time (AGENT): 389665 ms
Total Talk Time (CUSTOMER): 443712 ms
Interruptions: 4
Overall Sentiment: AGENT=0.4, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/10/564fad0c-e7e3-4243-aea7-b0f312814238_20250410T12:31_UTC.wav
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[AGENT][NEUTRAL] Good morning. Thank you for calling ICAO. This is [PII]. May I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. Good morning. Um, I'm giving you a call cause I'm having a couple issues submitting some claims. Um, I've done so in the past. We've had this insurance for 2 years now, but I guess ever since my newborn came into the policy, um, it seems like things are just not getting processed and then there's like duplicates of everything, so I'm just trying to get it sorted out.
[AGENT][NEUTRAL] OK. Do you have a phone number I can get in case I get dis disconnected I can call you back?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, [PII].
[AGENT][NEUTRAL] And may I ask who's calling?
[CUSTOMER][NEUTRAL] This is [PII].
[CUSTOMER][NEUTRAL] I'm [PII]'s wife. He's the policyholder.
[AGENT][NEUTRAL] OK. And do you have your policy number?
[CUSTOMER][NEUTRAL] Uh yeah. 233-9235.
[AGENT][NEUTRAL] Hold on one moment, please.
[AGENT][NEUTRAL] And what's your date of birth, Ms. [PII]?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you, Ms. [PII], and you had some questions about some claims?
[CUSTOMER][NEUTRAL] Yeah, so basically, um.
[CUSTOMER][NEGATIVE] Well, we can start with mine because I have I think 3 claims that are pending, um, and they say that uh APL is trying to contact the employer for verification of coverage and it's been like that for weeks. I don't, you know, we spoke to my husband's employer and they said that they haven't received anything from you guys in terms of.
[CUSTOMER][NEUTRAL] Uh, communications, so we're just trying to see what we can do to advance the processing of those claims because everything should be current in terms of coverage and.
[CUSTOMER][NEGATIVE] Um, things of that sort. So I just, I don't know why it's not getting processed.
[AGENT][NEUTRAL] OK, I can help you with that. What date of service was that for you?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] There's one from [PII], and then there's one for for [PII].
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] Yes, ma'am. They are pending. Let me see.
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][POSITIVE] No problem.
[AGENT][NEUTRAL] OK, it's pending, um, we received your claim, however, it is pending due to benefit renewal information from your employer and group. Once we receive that information, we'll continue processing your claim.
[AGENT][NEUTRAL] So we haven't seen.
[CUSTOMER][NEUTRAL] Well, did you guys reach out because the the employer said the HR person said that they haven't received anything from APL.
[AGENT][NEUTRAL] No, we do not uh we cannot reach out to the employer. We send you the explanation of benefits.
[AGENT][NEUTRAL] Letting you know why it's pending and they can.
[CUSTOMER][NEUTRAL] Right, but what I'm asking is, what I'm asking is what, what can we do to process this because the employer said that everything looks good on their end, so what do we have to do here?
[AGENT][NEUTRAL] Bye.
[AGENT][NEUTRAL] Your employer can contact our billing department.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Because I'm only showing the policies page 111 to 24.
[CUSTOMER][NEUTRAL] Sorry, the policy says what?
[AGENT][NEUTRAL] It's only paid 111 to 24, so.
[AGENT][NEUTRAL] They would need to, they would need to contact our billing department.
[CUSTOMER][POSITIVE] Oh wow, OK, very.
[CUSTOMER][NEUTRAL] Is that paid through date for both [PII] and I or just for.
[CUSTOMER][NEUTRAL] Myself.
[AGENT][NEUTRAL] That would be for any claims after 111 or 24.
[CUSTOMER][NEUTRAL] OK, understood. And then for my daughter [PII], um,
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] It's uh is she under the same belt here like not getting processed because of this payment issue?
[CUSTOMER][NEUTRAL] Because at first it said that her coverage had lapsed, she was just born a month ago, um, and added to this policy, but then I, I just got a claim. I submitted a claim for her for hospitalization and the explanation of benefits said that it wasn't processed because it's a duplicate of another claim, so.
[AGENT][NEUTRAL] OK, um, on that one now, it looks like we need information on that one. Let me see what it is.
[CUSTOMER][NEUTRAL] Because I just got I just got a notification that it said that.
[CUSTOMER][NEUTRAL] They completed. I it's claim number 3586226.
[CUSTOMER][NEUTRAL] It just says that this is a duplicate of another thing.
[AGENT][NEUTRAL] Yes, ma'am. It's just that.
[AGENT][NEUTRAL] It is a duplicate of a previous claim that you had sent in.
[AGENT][POSITIVE] But I can check on that for you.
[CUSTOMER][NEUTRAL] Yeah, what information do you need? Because I submitted, I submitted everything.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] OK. On that one, that was when she went to the emergency room on [PII]. It's the way they sent it in, the diagnosis, uh, is a wellness and wellness is not covered. They sent it in as the diagnosis is
[AGENT][NEUTRAL] Feared health complaint whom no diagnosis was made.
[AGENT][NEUTRAL] Now, you can call them and ask them about the diagnosis code.
[AGENT][NEUTRAL] What was the reason she went to the emergency room?
[CUSTOMER][NEUTRAL] Um, well,
[CUSTOMER][NEUTRAL] So we were at the pediatrician and she just had extremely low body temperature. So the pediatrician sent us to the ER. I have the note where the pediatricians, like I have the referral for the ER. I don't know if that would suffice.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] We would have to have something that's not a wellness diagnosis from the emergency room from that hospital.
[CUSTOMER][NEUTRAL] Would the, would the ER referral suffice or?
[AGENT][NEUTRAL] We would, uh, just, if you wanna call and ask them, just tell them we need a, a sickness diagnosis. They send in a wellness diagnosis.
[CUSTOMER][NEUTRAL] Um, OK, understood. And then what about for the Mount Sinai one for the inpatient expense?
[AGENT][NEUTRAL] Let me see what we need. I know we need some information on that one.
[CUSTOMER][NEUTRAL] Did the did the ER send something over because I don't.
[CUSTOMER][NEUTRAL] I, I'm I'm not sure what I submitted, um.
[AGENT][NEUTRAL] I can look, hold on, let me look at this one real quick.
[CUSTOMER][NEUTRAL] Yeah, of course, thank you, sorry, I know, I know there's like a lot of things floating out.
[AGENT][NEUTRAL] Oh, that's OK.
[AGENT][NEUTRAL] Let's see. In order to provide further consideration to this claim, please submit the item explanation of benefits from the primary insurance carrier, the diagnosis for which treatment was provided on this data service.
[AGENT][NEUTRAL] So we would need the diagnosis code and the explanation of benefits from the primary on the hospital bill.
[CUSTOMER][NEUTRAL] OK, I can, I can provide that, but let me ask you, how do I, like, how do I upload all of that because I feel like every time I I upload supporting documentation I create a new claim.
[CUSTOMER][NEUTRAL] So is there a way that you can tell me how to do this? Like how do I?
[AGENT][NEUTRAL] It will, yeah, it will, it will always create a new claim because when you upload it, it, it creates a new claim each time and then we'll review it, but we also go back and review what you've already sent in.
[CUSTOMER][NEGATIVE] Give you that information without clear.
[CUSTOMER][NEUTRAL] Got it. Um,
[CUSTOMER][NEUTRAL] OK, let me, let me see because I feel like I provided that already, um.
[CUSTOMER][NEUTRAL] The
[CUSTOMER][NEUTRAL] The EOB, I mean, and the diagnosis like I'm just opening it up here. Hold on.
[CUSTOMER][NEUTRAL] Sorry, just looking at this service dates.
[CUSTOMER][NEUTRAL] Yeah, I said that's weird. I, I sent this already.
[CUSTOMER][NEUTRAL] Are you guys not able to see it? It was, it was a claim for like.
[CUSTOMER][NEUTRAL] I think it was like $2,585.
[AGENT][NEUTRAL] Hold on just a second. I'm trying to get the claim to come up.
[AGENT][NEUTRAL] So I can see actually what we got.
[AGENT][NEUTRAL] OK, this is the first I'm gonna go claim by claim so I, I can explain it to you, um.
[AGENT][NEUTRAL] On this claim.
[AGENT][NEUTRAL] All we got was a bill from that you sent in from Mount Sinai. It doesn't have a diagnosis code on it. Let's see.
[CUSTOMER][NEUTRAL] That's the one for 25.
[AGENT][NEUTRAL] Yeah, I'll
[CUSTOMER][NEUTRAL] 2585.
[AGENT][NEUTRAL] Yes. And let me go to the next one. So all that was was a bill on that one. Let me see.
[AGENT][NEUTRAL] OK. This one was 28 pages.
[CUSTOMER][NEUTRAL] And then uh the the revenue, the revenue code is not the same as the diagnosis code, correct?
[AGENT][NEUTRAL] Right. The diagnosis code is the reason you went to the doctor or hospital. The procedure codes is what they've done while you were at that hospital or doctor's office.
[CUSTOMER][NEUTRAL] So I'm, I'm, I'm just looking at the EOB here from Cigna and they don't include diagnosis codes.
[CUSTOMER][NEUTRAL] Like it just says
[CUSTOMER][NEUTRAL] type of service.
[AGENT][NEUTRAL] Yeah, you'd probably have to call the hospital and ask them for, tell them you need a bill that has a diagnosis code on it.
[AGENT][NEUTRAL] Let's see. I'm looking through this one. It's 28 pages, so it'll take me just a second.
[AGENT][NEUTRAL] Uh, this one, I only see the diagnosis for that emergency room bill that was a wellness.
[AGENT][NEUTRAL] But I'm looking at all the pages. Hold on just a second.
[CUSTOMER][NEUTRAL] Oh wait, hold on, I found.
[CUSTOMER][NEUTRAL] So would the would would the after visit summary.
[CUSTOMER][NEUTRAL] Uh, be it, cause here it says patient diagnosis. This is for [PII], by the way. So it says patient diagnosis, reason for admission, newborn, quoted admission diagnosis, single live newborn.
[CUSTOMER][NEUTRAL] Code Z 38.
[AGENT][NEUTRAL] Let me see what
[AGENT][NEUTRAL] That's it.
[AGENT][NEUTRAL] And is that, is that for the 33 and 34 uh hospital bill?
[CUSTOMER][NEUTRAL] That's it, that would work.
[CUSTOMER][NEUTRAL] Yeah, that's correct. So that's, that's just for the birth of my daughter. So she was, uh, obviously admitted into the nurse, so that would work.
[AGENT][NEUTRAL] Yes, that
[AGENT][NEUTRAL] That's what we need and the explanation of benefits from Cigna.
[CUSTOMER][NEUTRAL] OK, are you able to, if I submit this now, are you able to see it live?
[AGENT][POSITIVE] I should be able to in the next few seconds, yes.
[CUSTOMER][NEUTRAL] OK, I'm, I'm just uploading everything, so I have 3 files for you the sign I bill, the explanation of benefits, and then the after visit summary. The diagnosis code is in the after visit summary and the second page.
[CUSTOMER][NEUTRAL] So let's see, submit.
[CUSTOMER][NEUTRAL] OK, one second, it's submitting, OK.
[CUSTOMER][NEUTRAL] You should be able to see now confirmation number 0SC 96,430.
[AGENT][NEUTRAL] OK, hold on, let me.
[AGENT][NEUTRAL] Finish looking at this bill real quick.
[AGENT][NEUTRAL] And you said you uploaded it for her?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yeah, it's confirmation OOSC 96,430 for [PII].
[AGENT][NEUTRAL] It must have not came through yet. Hold on.
[CUSTOMER][NEUTRAL] Yeah there's 3 files, um, OK, yeah, I mean if you can just see the after visit summary it's um it's the 2nd page.
[AGENT][NEUTRAL] There it is.
[AGENT][NEUTRAL] Hold on just a sec.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That have the diagnosis.
[AGENT][NEUTRAL] Hold on just a second, let me pull.
[CUSTOMER][NEUTRAL] It's under patient diagnosis.
[AGENT][NEUTRAL] Let me pull that mail up.
[AGENT][NEUTRAL] You said the 2nd page?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Well.
[CUSTOMER][NEUTRAL] So it
[CUSTOMER][NEUTRAL] You, you see where it says um.
[CUSTOMER][NEUTRAL] Patient diagnosis, that like right at the middle of the page.
[AGENT][NEUTRAL] Yes, that's it.
[CUSTOMER][NEUTRAL] OK, so there it has a Z38, that's the code.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Yeah, that's what we need. And did you send the explanation of benefits?
[CUSTOMER][NEUTRAL] And then the
[CUSTOMER][NEUTRAL] I did. So that's under a separate attachment.
[AGENT][NEUTRAL] Is it in with this diagnosis code claim?
[CUSTOMER][NEUTRAL] Sorry?
[AGENT][NEUTRAL] That uh uh never run I see it, I think.
[CUSTOMER][NEUTRAL] Yeah, no, it's um I think it's called [PII] Cigna 33.
[AGENT][NEUTRAL] I see it is on page 32.
[CUSTOMER][NEUTRAL] Oh yeah, sorry, I don't know how these get uploaded.
[AGENT][NEUTRAL] That's fine.
[CUSTOMER][NEUTRAL] They probably crammed them all. Um, yeah, so it's, it says, yeah, it's.
[AGENT][NEUTRAL] Coinsurance 48486. Yeah, we have that. So, we have everything to process this one, but it will also be pended when they process it for that.
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] Eligibility what from the employer.
[CUSTOMER][POSITIVE] OK, um, I can I can get that taken care of since I have you and like you are literally so helpful, can we just go through the ones that are pending for me just to make sure that everything that you need is in there?
[AGENT][NEUTRAL] We have everything? OK.
[CUSTOMER][NEUTRAL] Yeah, yeah, and then so then once the once the billing gets fixed, we can.
[AGENT][NEUTRAL] Let's go to yours.
[CUSTOMER][NEUTRAL] Just to make, just to make sure that um everything is in there. I, I really just have to. There's one for.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] 220, let's see.
[CUSTOMER][NEUTRAL] And then there's one for [PII].
[AGENT][POSITIVE] Looks like we have everything for those cause
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Because we asked for the diagnosis code and it looks like you send it, so it looks like we have everything for yours.
[CUSTOMER][NEUTRAL] For both, for both dates?
[AGENT][NEUTRAL] Right, for, well, for 2, that was for 220. Let's see. You said 32?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, there's one for 32. It's um OSC 95144.
[CUSTOMER][NEUTRAL] That was my hospitalization when I gave birth.
[AGENT][POSITIVE] Yeah, it looks like we have everything for that one as well.
[CUSTOMER][NEUTRAL] Yeah, I, I just, I just opened it. I sent like 14 attachments, so hopefully something that should be in there. OK. All right, so, and then for, for the, for my daughter's ER visit, I need to get an updated.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Like an updated diagnosis code, correct? From, from the hospital?
[AGENT][NEUTRAL] Yeah, what they sent in was uh Z71.1.
[CUSTOMER][NEUTRAL] That's really
[AGENT][NEUTRAL] Which is a wellness.
[CUSTOMER][NEUTRAL] Who, who sent that? The hospital send that because they actually haven't sent me any bills for that visit yet.
[AGENT][NEUTRAL] It looks like
[AGENT][NEUTRAL] It looks like you sent this one in for the ER.
[CUSTOMER][NEUTRAL] OK, I did. OK, I did. All right.
[CUSTOMER][NEUTRAL] Um, I will, I will check on that. Alright, so then I guess the only thing I have to do is, um, notify my husband's employer that they need to call you guys, um, because apparently there's been no payment for this policy since.
[CUSTOMER][NEUTRAL] November of last year.
[AGENT][NEUTRAL] Right, right.
[CUSTOMER][NEUTRAL] Is that correct?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All right. I will do that. Thank you so much. I really appreciate your help. You are fantastic.
[AGENT][POSITIVE] You're welcome. Is there anything else I can help you with?
[CUSTOMER][POSITIVE] No, that's it. Have a good day.
[AGENT][POSITIVE] Thank you, Miss
[AGENT][NEUTRAL] With cubism