AccountId: 011433970860
ContactId: 5d7e8dde-9f42-4300-893f-a4025931427d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 632659 ms
Total Talk Time (AGENT): 189938 ms
Total Talk Time (CUSTOMER): 237710 ms
Interruptions: 0
Overall Sentiment: AGENT=1, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/16/5d7e8dde-9f42-4300-893f-a4025931427d_20250516T18:53_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yes, this is a reference to a claim number 3600626.
[AGENT][NEUTRAL] OK, is it for yourself?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, let me get your policy pulled up. Just one moment.
[AGENT][NEUTRAL] And could you verify your name and your date of birth for me?
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][NEUTRAL] OK, thank you, Mr. [PII]. Um, and can you verify your address for me?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And and then you have a good callback number in case we're disconnected.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, um, let me pull up that claim, see what we've got.
[AGENT][NEUTRAL] OK, it looks like we needed additional information that showed um it looks like you've you've sent in some claims for lab work and then office visits, is that right?
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] The claim from the, the, uh, I can't separate the office visit from the lab work from the uh insurance uh claim insurance combined them onto one form, so I have to give you at least uh the uh insurance uh uh result so I sent that and then I sent the bill because it said uh that you needed some kind of itemized bill with the diagnostic code so I put the diagnostic code.
[CUSTOMER][NEGATIVE] On both the uh for the uh insurance uh explanation of benefits as well as the uh bill that I sent, I have no further information. This is the same thing that I've made claims on multiple times over the past 5 years.
[CUSTOMER][NEUTRAL] And these have gone through without such difficulty. I understand you're not gonna cover the doctor's visit. I can't separate that from the process, but the lab pl diagnostics is the same as it was in uh the three last ones plus all the ones from last year.
[AGENT][NEUTRAL] OK, looks like, yes, I'm pulling up what we received. I see the codes, um.
[AGENT][NEUTRAL] Looking for a diagnosis. That's what I think we're, OK, diagnostic code. I see that.
[AGENT][NEUTRAL] And then, uh, OK.
[AGENT][NEUTRAL] Or 2
[AGENT][NEUTRAL] Let me make sure we just didn't, we may have just missed it.
[CUSTOMER][NEGATIVE] Yeah, I mean, it's extremely unfortunate that the insurance company with their explanation of benefits does not provide that information to you because they have the agreement with you to provide information, but whatever it is, you can come back to me to find the codes that the doctor used for the prescription that doesn't flow through the system. So I put that in the paperwork that I sent. I didn't do the first time. That's on me.
[CUSTOMER][NEUTRAL] Uh, I did it on the second, uh, one that I filed on [PII] along with the bill as requested.
[AGENT][NEUTRAL] OK, yeah, I see that. Um, let's see, make sure I'm not missing anything.
[AGENT][NEUTRAL] OK, let me, um, let's see.
[AGENT][NEUTRAL] Let me get you to our claims department so they can get this sent back through um I'll give them all the information that you provided and then they can get this sent back through for processing. Do you mind uh if I transfer you over there?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Hold on one moment, OK?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How may I help you?
[AGENT][NEUTRAL] Hey, [PII], it's [PII] on the care team. I've got an insured on the line that, um, I pulled up the claim and I, I can't see what we're missing cause I do see diagnosis codes and procedure codes.
[AGENT][NEUTRAL] Um, so can you help me with that and look at it?
[CUSTOMER][NEUTRAL] Certainly, what's the policy number?
[AGENT][NEUTRAL] Um, policy number is
[AGENT][NEUTRAL] 01660267.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Give me one moment.
[CUSTOMER][NEUTRAL] And it's from [PII].
[AGENT][POSITIVE] Yes, that's right.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, it's at 36002626, the most recent claim.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEGATIVE] And it looks like they that one was denied.
[CUSTOMER][NEUTRAL] Is duplicate so I'm gonna also look at that previous mail. It doesn't, I don't see a diagnosis code so let me look at.
[CUSTOMER][NEUTRAL] What must be missing.
[AGENT][NEUTRAL] Yeah, I see, I see a diagnosis code on page 6, or let's see, is it 7.
[AGENT][NEUTRAL] It's, it's in, it's kind of a lighter gray color and it's underneath the
[AGENT][NEUTRAL] Itemization of the CPT codes, it's on the right.
[AGENT][NEUTRAL] Some, uh, 6 of my CD 10 cos.
[AGENT][NEUTRAL] I'm not sure what we're missing, nor was I sure what it was a duplicate too, cause I can't find.
[AGENT][NEUTRAL] Um, where the duplicate.
[CUSTOMER][NEUTRAL] OK, it looks like there's a couple different dates of service [PII].
[CUSTOMER][NEUTRAL] And that previous mail.
[AGENT][NEUTRAL] Oh, I see the [PII]. I, I do see that duplicate, but.
[AGENT][NEUTRAL] We've got the diagnosis codes and CPT codes. I wasn't sure what where we're.
[AGENT][NEUTRAL] It's eligible to be processed or not.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah, it said no diagnosis code provided on the 4929, but it's on the 360062.
[AGENT][NEUTRAL] 6.
[CUSTOMER][NEUTRAL] OK, I'm looking at that now. It's just taking a long time to load my apologies.
[AGENT][POSITIVE] Oh, no, no worries.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, page 7, is that the page you were referring to from the quest, right?
[AGENT][NEUTRAL] Uh-huh. Had the diagnostic code in 18.2, and 25.8 E 11.21.
[CUSTOMER][NEUTRAL] Yes, I see it right now uh huh, 11.21 they did provide the diagnostic code there. OK, so, um.
[CUSTOMER][NEUTRAL] You can do
[CUSTOMER][NEUTRAL] I would just um let the um you have the.
[CUSTOMER][NEUTRAL] Insured on the line you said correct?
[AGENT][POSITIVE] Yes, I do.
[CUSTOMER][NEUTRAL] OK, you can just let them know that you're gonna send it back for review, um, and allow, um, and allow some time for that process and usually I just um like 1 to 3 business days, um, and it should be reprocessed, um, and then.
[CUSTOMER][NEUTRAL] I can, uh, I guess you probably would want to go ahead and send a hub request and then um or I can do that if you'd like either way but yeah we should send a hub request and then what I'm gonna do is I'll go ahead and take the information right now and put it into our um claims review so if you want to do that um.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I'll go ahead and start that process as well.
[AGENT][POSITIVE] OK, perfect. I'll do a hub request and I'll let him know to just allow up to 3 working days. Does that sound good?
[CUSTOMER][POSITIVE] Yes, mhm, yeah, for that claim turnaround, that's correct, OK.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK, perfect. OK, thank you so much.
[CUSTOMER][NEUTRAL] You're welcome, [PII].
[AGENT][POSITIVE] Thank you, bye bye.
[CUSTOMER][POSITIVE] Have a good day bye.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] OK, I'm so sorry about the long hold. OK, we're getting that reprocessed, Mr. [PII]. This is [PII] still, um, it'll just take about 1 to 3 business days. They just missed that diagnostic code. I, I, they see that, so it's gonna go back through the processing, um, and like I said, just give it about 3 business days and that'll be pre-processed. Sorry about that.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right, I follow.
[CUSTOMER][NEUTRAL] On the same uh claim number?
[AGENT][NEUTRAL] Yes, uh, no, it'll it'll.
[CUSTOMER][NEUTRAL] Will, will I use the same claim number?
[AGENT][NEUTRAL] It won't be the same claim number, it'll be a new one.
[CUSTOMER][POSITIVE] That's what I figured, OK, I'll watch out for that. All right. Thank you again for your assistance. Anything else you need from me?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, no. Anything I can help with further?
[CUSTOMER][POSITIVE] No, we'll just wait for the results the next process here. Thank you very much bye bye.
[AGENT][POSITIVE] Thanks for calling APL. Bye bye.