AccountId: 011433970860
ContactId: 5cc2d83f-9b44-486a-82ab-a659938cc9a9
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 804159 ms
Total Talk Time (AGENT): 344123 ms
Total Talk Time (CUSTOMER): 286599 ms
Interruptions: 3
Overall Sentiment: AGENT=0, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/08/5cc2d83f-9b44-486a-82ab-a659938cc9a9_20250408T17:27_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yes, hi [PII]. I'm calling regarding a claim I had submitted for my client that was not processed, and I'm calling to find out why.
[AGENT][NEUTRAL] OK, yeah, let's take a look. Do you have the claim number or policy number?
[CUSTOMER][NEUTRAL] Yes ma'am, the claim num, which one do you want the claim number?
[AGENT][POSITIVE] Yeah, you can give me that. That's perfect.
[CUSTOMER][NEUTRAL] 357.
[CUSTOMER][NEUTRAL] 4382.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then I will need to verify the insured's name and date of birth, please.
[CUSTOMER][NEUTRAL] Sure, it is [PII].
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] And hold on, let me get you the rest of his information. Give me one moment.
[CUSTOMER][NEUTRAL] Let me pull up the claim form.
[CUSTOMER][NEUTRAL] [PII], date of birth [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, so.
[AGENT][NEGATIVE] Looks like a portion of it was denied just stating that office visits are not covered under the policy.
[CUSTOMER][NEUTRAL] OK, but, OK, can.
[CUSTOMER][NEUTRAL] We didn't submit it for an office visit, we submitted it for an MRI. We even highlighted the explanation of benefits from um United Healthcare with the charges that we were submitting in addition to the paid receipt that he paid the provider for the MRI.
[CUSTOMER][NEUTRAL] That's the only charges that we were submitting were for the 332. I think it's 332.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] 33276.
[AGENT][NEUTRAL] Let me look at the claim form.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] Sorry, this is just taking a minute to load.
[AGENT][NEUTRAL] It's a lot of pages.
[CUSTOMER][POSITIVE] No problem.
[CUSTOMER][NEUTRAL] Yeah, I know, sorry. I know next time should I just not send that many? Like should I just send the highlight in?
[AGENT][NEUTRAL] It's OK.
[AGENT][POSITIVE] No, no, no, it's no, it's totally fine.
[AGENT][NEUTRAL] I see the explanation of benefits.
[CUSTOMER][POSITIVE] And even highlighted it in yellow.
[CUSTOMER][NEUTRAL] It's an MRI for his prostate. That's why they're asking for accident, like there was no accident.
[CUSTOMER][NEGATIVE] I don't even know what you guys are asking for.
[AGENT][NEUTRAL] Yeah, so.
[AGENT][NEUTRAL] The other denial says.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Procedure of the claim is acknowledged, however, in order to provide further consideration, we need a diagnosis code.
[CUSTOMER][NEUTRAL] It was on the receipt.
[CUSTOMER][NEUTRAL] The CPT code.
[CUSTOMER][NEUTRAL] Hm, maybe that's why.
[AGENT][NEUTRAL] Yeah, I see the CPT code, but I don't know. Let me see.
[CUSTOMER][NEUTRAL] Let me see.
[AGENT][NEUTRAL] Yeah, so the CPT code.
[AGENT][NEUTRAL] Is
[AGENT][NEUTRAL] Yeah, for the for the procedure.
[CUSTOMER][NEUTRAL] Is there
[CUSTOMER][NEUTRAL] Yeah, it's for prostate cancer, right?
[AGENT][NEUTRAL] Right, and they're asking for diagnosis.
[AGENT][NEUTRAL] Um, what I can do on this one is send it back to the claims examiner and have somebody contact you directly on it, have them re-review it to see if there's anything else that they have missed if it was, you know, an error on our side, then they can reprocess it.
[AGENT][NEUTRAL] Um, would you guys be OK with a call back on it?
[CUSTOMER][NEUTRAL] Yeah, that'll be fine.
[AGENT][NEUTRAL] That's a good callback number?
[CUSTOMER][NEUTRAL] Do you know how
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, and then what was your first name again? I'm sorry.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Um, so generally we
[CUSTOMER][NEUTRAL] Yeah, it's just, it's just, mhm, sorry.
[AGENT][NEUTRAL] Go ahead, I'm sorry.
[CUSTOMER][NEGATIVE] No, no, it's just so confusing because like they put all the charges. That's what I'm saying. I don't know how to make it.
[CUSTOMER][NEUTRAL] Like cleaner for next time, so they don't try to process things we're not submitting.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] You know what I'm saying?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, cause it was 4 different
[CUSTOMER][NEUTRAL] Like I was only submitting the claim for, right, and I was only submitting the claim for [PII], because that's the MRI. I know an office visits not covered, and the lab we weren't doing, we were just doing the MRI which were the two [PII] pair that charged him 500, but it was only 3, whatever, what United agreed.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] OK.
[AGENT][NEGATIVE] Gotcha.
[AGENT][NEUTRAL] Right.
[AGENT][NEGATIVE] OK, I see what you're saying, yeah, and it carried over on the 123 of 25, and that wasn't even applicable. OK, I, I see what you're saying.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEGATIVE] Right, right. No, this guy's an attorney, so it's like, oh my God, every time you guys deny something like this, it's like.
[AGENT][NEUTRAL] OK, yeah.
[AGENT][NEGATIVE] Oh, it's a headache for you. I
[CUSTOMER][NEUTRAL] He's like, he's like they have the, yeah, yes, because it's like they have the EOB they have the receipt, what more do they, and it's, he's right, in a way he's right, because like, obviously if United covered it, it should have been covered, so why wouldn't the gap cover it, you know, whatever.
[AGENT][NEUTRAL] Yeah, yeah.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Mhm, mhm.
[CUSTOMER][NEUTRAL] He's an attorney. What can I tell you?
[AGENT][NEUTRAL] Girl, look, I get it. I mean, I, I had some yesterday that I was just, yeah, I had a couple yesterday that it's like we deal with a third party like staffing agency, so they get the they get the benefits through the staffing agency, you see what I'm saying? And you know, the insured is like wanting the claim paid, but we're waiting for information from the staffing agency.
[CUSTOMER][NEUTRAL] What can I tell you?
[CUSTOMER][POSITIVE] Oh my [PII], so much patience.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] And it was like a back and forth, you know, and I, anyways, I ended up calling the staffing agency [PII], and I told the staffing lady, I said, look, you know, I like you too much just to transfer this lady over to you, OK?
[CUSTOMER][POSITIVE] Wow.
[CUSTOMER][NEUTRAL] 4
[CUSTOMER][NEGATIVE] But she's gonna destroy you.
[AGENT][NEGATIVE] I was like, right, I was like, she is coming in hot, you know, um, she is upset.
[CUSTOMER][POSITIVE] Yeah, I know, like, he's like, why haven't they covered it? They have everything they need. Didn't you submit the EOB with it? Yes, I did, like I always do.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Right, OK, so [PII], what I'm gonna do then in this call back is say that you need clarification on this, but then I'm also gonna put in the notes and you can definitely ask when they call you um I'm gonna put in there that, um, you know, please explain in the future how to better submit claims if it's just for a single date to avoid any sort of.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEGATIVE] Because you have lines in here that aren't even applicable that you're not even worried about, you know, so.
[CUSTOMER][NEUTRAL] Right, right, that, and that's why I go through the trouble of highlighting his EOB so that I think it would stick out like this is what we're submitting.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] But maybe like I said, maybe I need to clean out and
[AGENT][NEUTRAL] Something, right.
[CUSTOMER][NEUTRAL] Like not have submitted that last page.
[AGENT][NEUTRAL] The 3:30 because I, yeah, I see the.
[CUSTOMER][NEUTRAL] Wow, I don't know. I mean, I don't know what else to do.
[AGENT][NEUTRAL] I see the 3:32.
[AGENT][NEUTRAL] So, yeah, I mean, from what I'm reading is just that they're needing, um, they know what was done as far as the procedure because we have those codes. What I am reading it as is that they want, what was the diagnosis of the procedure? Was there any diagnosis?
[AGENT][NEUTRAL] Why was the procedure, was there a diagnosis, you know, for the need of the procedure? That's what I'm taking from it.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] But I'm gonna have them call you and clarify just to make certain because I don't want you to be trained to gather information to submit on his behalf and then it's, you know, I, yeah, I don't want you to waste time submitting things that aren't needed, but that's how I'm reading that denial is that they have the code.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] All right. No, because if
[AGENT][NEUTRAL] For what they did, but they need to know what the diagnosis was.
[CUSTOMER][NEUTRAL] Right. So,
[CUSTOMER][NEUTRAL] What the ICD code is.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, yeah, so often, yeah, it's the ICD 10 code.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, that we're needing.
[CUSTOMER][NEUTRAL] Right, and let me ask you, would they take it over the phone? Would they take it over the phone, or no? I'd have to submit it again on the portal.
[AGENT][NEUTRAL] You'll have to submit it. They used to take him over the phone, but not anymore.
[AGENT][NEUTRAL] So what you could do, [PII] is just um upload that you don't need to resubmit everything.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Just on that denial form, put it.
[AGENT][NEUTRAL] Mhm, mhm. And then you can write down the
[CUSTOMER][NEUTRAL] Not the denial. I don't know what would you call that, uh.
[CUSTOMER][NEUTRAL] I guess it is like, right.
[AGENT][NEUTRAL] They, yeah, and you could just write the claim number on it.
[CUSTOMER][NEUTRAL] The explanation of benefits.
[AGENT][POSITIVE] There you go, yes.
[CUSTOMER][NEUTRAL] Right. I, I'll just, yeah, on the explanation of benefits, I'll fill in the ICD number.
[AGENT][POSITIVE] Mhm. You can do that. Yeah.
[CUSTOMER][NEUTRAL] And um and upload it, right?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, because that's the
[CUSTOMER][NEUTRAL] And you don't think, you don't think they'd do without it, huh?
[AGENT][NEUTRAL] No, I mean, uh.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][POSITIVE] Wow, thanks.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh my [PII], I know.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, I mean,
[CUSTOMER][NEGATIVE] Um, then don't even bother having him calling me.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And that's what it is and I'll, I'll just, yeah, I'll get it and upload it. It, I uploaded today how long?
[CUSTOMER][NEUTRAL] It shouldn't take that long, right? To be reprocessed.
[AGENT][NEUTRAL] No, it should just take a few days. They
[CUSTOMER][POSITIVE] Usually they're pretty fast.
[AGENT][NEUTRAL] Yeah, they generally ask for 5 to 7 days, but that's on new claims, so, um.
[CUSTOMER][NEUTRAL] Yeah, OK, I'll let him know. I, I'll let him know like 2 weeks. OK. All righty, thank you.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right, [PII].
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][POSITIVE] Have a good day.
[AGENT][NEUTRAL] You too, bye.
[CUSTOMER][POSITIVE] Take care.