AccountId: 011433970860
ContactId: 5fe714da-07f8-49b5-9cdb-2e6f5a7da7ae
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 834719 ms
Total Talk Time (AGENT): 205754 ms
Total Talk Time (CUSTOMER): 275160 ms
Interruptions: 1
Overall Sentiment: AGENT=0.2, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/20/5fe714da-07f8-49b5-9cdb-2e6f5a7da7ae_20250320T16:13_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Did you say easy?
[AGENT][NEUTRAL] Um, EV
[CUSTOMER][NEUTRAL] Oh, easy. Hi. Uh, my name is [PII]. I was just online and I see that, um, out of all the claim that I put in, only one was processed.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Uh, 311.
[CUSTOMER][NEUTRAL] I just wanted to know the status.
[AGENT][NEUTRAL] OK, yes, ma'am. I can assist you with claim status. Um, first, could I get a good callback number just in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Thank you. Now, could I get your policy number, please?
[CUSTOMER][NEUTRAL] OK. 01.
[CUSTOMER][NEUTRAL] 699394 ML 7 and ML 8.
[AGENT][NEUTRAL] OK, thank you. Now, please verify um your name again and your date of birth.
[CUSTOMER][NEUTRAL] [PII], [PII].
[AGENT][NEUTRAL] OK, one moment, please.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, and what's the date of service and bill charges on the claim you're calling about?
[CUSTOMER][NEUTRAL] Uh, it, it's quite a bit of them. I submitted there was one from um.
[CUSTOMER][NEUTRAL] I have to go here. Um, there were, I had my hand surgery [PII].
[CUSTOMER][NEUTRAL] And um I had an emergency room service, I think [PII] or [PII].
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] And then there was the therapy and stuff like that that um
[CUSTOMER][NEUTRAL] The um
[CUSTOMER][NEUTRAL] person that I had spoken to.
[CUSTOMER][NEUTRAL] She told me what I needed back in [PII]. She told me what I needed. I called um the facilities and I had all of them submitted, so I'm not sure.
[CUSTOMER][NEUTRAL] I see that only one was processed.
[AGENT][NEUTRAL] OK, yes, ma'am. I'm showing that these claims, let's see.
[CUSTOMER][NEGATIVE] I submitted 7, and out of the 7, only 1 was um.
[CUSTOMER][NEUTRAL] Was paid and I'm just wondering is there um any kind of information that I need other than what I submitted? What do I need to have in order to um.
[CUSTOMER][NEUTRAL] To get the information from them.
[AGENT][NEUTRAL] OK. Yes, ma'am. The information that we need is the EOB from your primary insurance company and we also need your
[CUSTOMER][NEUTRAL] I send those.
[AGENT][NEUTRAL] Your diagnosis code. You sent the explanation of benefits. Let me take a look at the images.
[CUSTOMER][NEUTRAL] Oh, the
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] From Blue Cross and Blue Shield.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And one moment, uh, it takes a moment for the system to open up the images, one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Right, thank you.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, ma'am. Thanks for your patience. Um, I'm showing, yes, ma'am. I'm showing for date of service [PII] for the anesthesia charges for the surgery.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] We need your diagnosis code for that. So if you can resubmit um documentation with your diagnosis code um for that date of service, we can get that reprocessed for you. And we also
[CUSTOMER][NEUTRAL] You said 611, right?
[AGENT][NEUTRAL] Right. And we also need the diagnosis code for 923 of 24 for anesthesia charges as well.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And let's see.
[CUSTOMER][NEUTRAL] OK, I'll, I'll call them both. I thought they submitted all of that to me because it happened in two different areas. The hospitals sent me the EOB and um.
[CUSTOMER][NEUTRAL] I sent it, uh,
[CUSTOMER][NEUTRAL] To you guys, but.
[AGENT][NEUTRAL] Yeah, we have the EOB but we need your diagnosis code. The diagnosis code is the code for the illness, the reason why you're having the surgery, and you can get that, right. You can get that from the provider's office. And let me give you the, let me give you the claim number. So when you do submit that documentation, just let us know that it's for this claim.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] F
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] If you're ready.
[CUSTOMER][NEUTRAL] Ha ha, OK.
[CUSTOMER][NEUTRAL] Yes, I am.
[AGENT][NEUTRAL] The claim number is 35. Mhm.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] 35
[AGENT][NEUTRAL] 758.
[CUSTOMER][NEUTRAL] 758.
[AGENT][NEUTRAL] 10.
[CUSTOMER][NEUTRAL] 10 that's what um so it's 611 correct.
[AGENT][NEUTRAL] Right, that's for [PII] and [PII]. We need the diagnosis codes. Yes, ma'am, for those services. Yes.
[CUSTOMER][NEUTRAL] For both, for both of them.
[CUSTOMER][NEUTRAL] OK. All right. I will call them today and see if they'll um just send them to me then I'll forward it to you. Anything else you're waiting on?
[AGENT][NEUTRAL] Well, I'm just letting you know that also, do you see where the denial is um D1M0119? Do you see those denials?
[CUSTOMER][NEUTRAL] I don't see any of that. All I saw is process, process, but there's no denial. I don't see any denial on here.
[AGENT][NEGATIVE] OK, well, there's also denials, and those are denials for services that was provided in office and under your policy, unfortunately, services provided in office is not covered and that's why those denied.
[CUSTOMER][NEUTRAL] OK. I, I don't have that yet.
[AGENT][NEUTRAL] So those can't be.
[AGENT][NEUTRAL] Right. Those can't be processed. Mhm.
[CUSTOMER][NEGATIVE] It it's not showing.
[CUSTOMER][NEUTRAL] OK, so I thought she told me um you guys cover therapy.
[AGENT][NEUTRAL] Well, physical therapy is covered when it's done in the office.
[CUSTOMER][NEUTRAL] Yeah, physical therapy, that's what I had. If it's done in the office, it's not covered?
[AGENT][NEGATIVE] Well, if it's done in an office, it is covered, but according to the documentation that we received, these services were not for physical therapy, and that's why they denied. These were services for office visits.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEGATIVE] No, there are office visits that the insurance company pay and I had to pay $35.
[CUSTOMER][NEUTRAL] As my copay.
[AGENT][NEUTRAL] For physical
[CUSTOMER][NEUTRAL] And then for my hand surgery, for physical therapy on my hand.
[CUSTOMER][NEGATIVE] Um, I went there 3 weeks, 3 times a week, and every time I go I pay $30.
[AGENT][NEUTRAL] OK. Yeah.
[CUSTOMER][NEUTRAL] Because they have a special part that they do their um physical therapy up on the 3rd floor.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEGATIVE] Yeah, well, according to these documentation, the documentation we received, this was for services done in office. This was for an office visit and that's not covered.
[CUSTOMER][POSITIVE] Oh no, OK, uh, I will, I will call them because they send me the bill and I have all the bills right here but you good.
[AGENT][NEUTRAL] But
[CUSTOMER][NEGATIVE] These people are driving me crazy. Right now, my problem, I have two herniated discs, and I need to go see someone.
[CUSTOMER][NEUTRAL] And that was way back.
[CUSTOMER][NEUTRAL] They keep going, I keep calling everyday, Saturday.
[CUSTOMER][NEUTRAL] I had to go to the office to get a copy of my MRI.
[CUSTOMER][NEUTRAL] So that I can go see a physician in, in regards to the MRI and what therapy I need after.
[CUSTOMER][NEUTRAL] I've been going back and forth, back and forth with these people. This is crazy.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah. I apologize, ma'am, but once you get that in.
[CUSTOMER][NEUTRAL] But you don't
[CUSTOMER][NEUTRAL] No, that's right. I understand. I understand your, um, your part. But then, do you cover, um, radiology? You don't?
[AGENT][NEUTRAL] Yes, ma'am. That is covered under your policy. Again, we would need the EOB from your primary insurance company and we would need your diagnosis code. And again, you can get that from your um doctor's office.
[CUSTOMER][NEGATIVE] Yes, I am about to call them and raise some hell. I hate that.
[CUSTOMER][MIXED] I hate that. Well, thank you very much for what you just tell me. I'm gonna call them right now and see what I can get.
[AGENT][NEUTRAL] OK. Is there anything else that I can assist you with?
[CUSTOMER][POSITIVE] Thank you so much.
[CUSTOMER][POSITIVE] No, ma'am. I'll call you back. Thank you.
[AGENT][POSITIVE] OK, thank you, [PII] for calling APL. You have a great rest of your day. Mm bye.
[CUSTOMER][POSITIVE] Likewise, thank you.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Hello?