AccountId: 011433970860
ContactId: 60e123d1-f5df-4b6c-b6ff-a2f4dababe74
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 989690 ms
Total Talk Time (AGENT): 352211 ms
Total Talk Time (CUSTOMER): 603667 ms
Interruptions: 3
Overall Sentiment: AGENT=0.3, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/08/60e123d1-f5df-4b6c-b6ff-a2f4dababe74_20250108T19:32_UTC.wav
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[AGENT][NEUTRAL] Calling APL, this is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII]. Um, I was calling because I have the additional information as to why you rejected my um.
[CUSTOMER][NEUTRAL] Claims for um my two sons, so I was just wondering like I'm on my claims page in APL. How do you guys want me to upload this additional information?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] OK, let me get your name and your policy number and then I can walk you through that, OK?
[CUSTOMER][POSITIVE] Perfect. Um, it's [PII]
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And then my policy number is 0165.
[CUSTOMER][NEUTRAL] 3654
[AGENT][NEUTRAL] OK, what's a good phone number, [PII] in case we're disconnected?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] [PII]. OK, I'm gonna pull up your account, get you verified, and then we can move to the online service center, OK?
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] You're welcome and verify your date of birth, your mailing address and then your email address on file for me.
[CUSTOMER][NEUTRAL] Yep, it's [PII] is my date of birth and then my mailing address is [PII], and then my um.
[AGENT][NEUTRAL] Email?
[CUSTOMER][NEUTRAL] What was the other thing email yes ist [PII].
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK, thank you for that information. So you are already logged on to the online service center?
[CUSTOMER][NEUTRAL] Yes ma'am, I'm in my claims area.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, so you're at the claims dashboard so you should see uh to the right an upload document button.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, and so you would have saved your documents to your desktop or laptop has that been done?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, so click the upload button.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then
[CUSTOMER][NEUTRAL] Let's see select files.
[AGENT][NEUTRAL] Uh-huh, select the correct policy. You may only have the only policy.
[CUSTOMER][NEUTRAL] And then the last time I
[AGENT][NEUTRAL] Yeah, the mainly.
[CUSTOMER][NEUTRAL] Yeah, I only have the one policy so I had a quick question. So so this is for [PII] that I'm uploading it was for data service like a while ago, but he should have had coverage during that time, um.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Yeah, because it said please provide a diagnosis code for this. So what I put John David CPT code is what I.
[CUSTOMER][NEUTRAL] Like, put out the
[CUSTOMER][NEUTRAL] File name, is there any other information that I need to put in there or will they know like what?
[AGENT][NEUTRAL] What what about putting your policy number?
[CUSTOMER][NEUTRAL] The diagnosis
[CUSTOMER][NEUTRAL] Oh, I gotta put my policy number.
[AGENT][NEUTRAL] Yeah, what is it asking for?
[CUSTOMER][NEUTRAL] So the for the rejection I got it says please provide a diagnosis code for this state of service.
[AGENT][NEUTRAL] Oh, OK, you're talking about the ELB OK, right, and it should be on the document that you got that you obtained.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yes, the document that I have had the CPT codes in it like it almost looks like it's a bill basically, but it does have the name and then the code.
[AGENT][NEUTRAL] OK, so it has the CPT codes, is, does it have the diagnosis code as well?
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Two different codes.
[CUSTOMER][NEUTRAL] Shit, OK, let me call them.
[AGENT][NEUTRAL] So the procedure code is what they did and the diagnosis code is the why, OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So they need diagnosis codes too.
[AGENT][NEUTRAL] Um, that's basically I think what the remark code says. Let me pull up the remark code real quick.
[CUSTOMER][NEGATIVE] Yeah, it just says that. What the heck.
[AGENT][NEUTRAL] Yeah, please provide the diagnosis code and you can send what you have, the procedures. It's not gonna hurt anything, but they will need the diagnosis code or you can say the ICD 10 code. That's the doctor's office.
[CUSTOMER][NEUTRAL] I see 10 that's, yes, ICD 10 code so I'm gonna have to call them back because she's like, oh they're on there and I'm like I obviously didn't use the right terminology, OK.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Like
[AGENT][NEUTRAL] OK, and are you sure it's not on there?
[AGENT][NEUTRAL] It's usually it's usually letters and numbers.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah, no, I don't see that because I used to work in um healthcare a while back, so that makes sense. It's literally just the number, so I'm like shit, yeah, the procedure code basically is what it is. I just forgot what it's called, so I obviously didn't call ICD 10. I remember that, but it took me a while, so OK.
[AGENT][POSITIVE] Oh, great. OK, you get it.
[AGENT][NEUTRAL] Yes, OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] I will call them again thank you.
[AGENT][NEUTRAL] And so that's where you would upload it and then click some you know submit and wait until you you should get a confirmation number and you wanna write down your confirmation number.
[CUSTOMER][NEUTRAL] OK, so I know I'm selecting these files like separately. Will the claims department be able to put 2 and 2 together, or should I like wait to upload everything together or like what's the best way to go about this?
[AGENT][NEUTRAL] Whenever it's when
[AGENT][NEUTRAL] And so, so are you saying you're uploading one document at a time?
[CUSTOMER][NEUTRAL] Yeah, well, that's what I'm saying cause the last time I had a confirmation number of, I think it.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] When did I upload this? I'm maybe I'll just do a whole new line on by itself. OK, yeah, so do I just upload it like I don't know. I don't know what's the best way to go about it.
[AGENT][NEUTRAL] Yeah, I see it.
[AGENT][NEUTRAL] I see it.
[AGENT][NEUTRAL] You you you can't, you cannot add it to an existing one you previously uploaded so you're gonna create a new record, so it's gonna be a new entry if that's it's the easier way to put it so you're gonna get a new or different confirmation number.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, but is it OK to upload documents like that or should I like upload everything all together?
[AGENT][NEUTRAL] And so
[AGENT][NEUTRAL] So it can't be over uh there is a file size and it cannot exceed.
[AGENT][NEUTRAL] Let me see. I think it's 20.
[AGENT][NEUTRAL] Megabytes.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] You cannot exceed that and even if you uploaded the documents individually like one at a time, which means you're gonna get a confirmation number for each, that's OK too because when they go to work your file they're gonna pull everything that's that's waiting to be processed.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, so I guess quick question for you because this might answer my question for my son's date of service for [PII], he was the only son I had at that time. Did he have $3000 still for his account or no? Can you see that?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So is this I can is this for inpatient or outpatient?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] It was in the hospital.
[AGENT][NEUTRAL] OK, I'm looking at the claim.
[AGENT][NEUTRAL] And
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Looks like it's inpatient.
[AGENT][NEUTRAL] So there's several dates of service.
[AGENT][NEUTRAL] On this claim
[CUSTOMER][NEUTRAL] On
[AGENT][NEUTRAL] There's uh January, yeah, and it's coded as inpatient. So do you have the diagnosis code for each date of service?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Um, I was mostly looking at the one that was here for [PII]. I do I have a submission for?
[AGENT][NEUTRAL] OK, [PII].
[CUSTOMER][NEUTRAL] Yeah, [PII] it looks like [PII] and [PII] and [PII] is what I have a bill for that I'm looking at right now. That's the one I'm talking about. The other one, the $350.01 I, I'll probably just because that is documentation from a different one. That one I'm not as concerned about as this $932 bill I'm looking at staring me in the face.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Got it. OK. OK.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So I guess I'm wondering if I still if I had funding at that time for him.
[AGENT][NEUTRAL] OK, so this is your [PII]. Let me go back and I can check that for you.
[CUSTOMER][NEUTRAL] Um
[AGENT][NEUTRAL] Actually this is the only claim that we have on file for [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] Yeah, because the other hospital one I have to find a diagnosis code and a CCT code for, I mean ICD 10. I keep saying, uh.
[CUSTOMER][NEUTRAL] ICD 10.
[AGENT][NEUTRAL] Yeah, and, and it looks like the inpatient benefit is $3000 per calendar year, so this is, this is his only claim so that amount is um gonna be it's available for 22.
[CUSTOMER][NEUTRAL] Diagnosis.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Covered
[CUSTOMER][POSITIVE] Perfect.
[AGENT][NEUTRAL] Yeah
[CUSTOMER][POSITIVE] Perfect. And then yeah, I think we only have like 350 for the other years.
[CUSTOMER][NEUTRAL] I think like 2-350s.
[CUSTOMER][NEUTRAL] But that was for like ER so I don't know if that'd even be.
[CUSTOMER][NEGATIVE] Cover, but I'll just scrounge up that and worst case scenario you guys deny it if I have all the right.
[CUSTOMER][NEUTRAL] Um, documentation for it.
[AGENT][NEUTRAL] For which one?
[CUSTOMER][NEUTRAL] Um, I think there's another like $350 for my son [PII], but I might not have put it down right.
[AGENT][NEUTRAL] Is that for
[CUSTOMER][NEGATIVE] I might not have submitted it correctly.
[AGENT][NEUTRAL] Oh OK well submit.
[CUSTOMER][NEUTRAL] An ER visit.
[AGENT][NEUTRAL] They are let me look. Was it submitted with the documents that we're looking at now?
[CUSTOMER][NEUTRAL] I think on accidents.
[AGENT][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] I might just have to get myself organized, to be honest with you.
[AGENT][NEUTRAL] Let me look at your outpatient. So, was he admitted through the emergency room?
[CUSTOMER][NEUTRAL] There's so much.
[CUSTOMER][NEUTRAL] 2
[CUSTOMER][NEUTRAL] There was one we had an um an admission for and then there was one that we weren't admitted so it'd probably be the one admitted so the [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] That one we just went to the ER we were not admitted, but the other [PII], I think it was like [PII].
[CUSTOMER][NEUTRAL] [PII] something or like in the [PII] where we did get admitted for a night.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let me see, I'm trying to see what your um.
[AGENT][NEUTRAL] Outpatient benefit.
[CUSTOMER][NEGATIVE] And I'm sorry, this literally this has taken me so long because Aetna kept denying his claims like the first year of his life, well, not first year, 1st 90 days of his life because they thought my husband's insurance automatically picked him up, which was not true, and they, it was awful. I like I had to fight them for 2 years on this. It was terrible.
[AGENT][NEUTRAL] Mhm. Mhm.
[AGENT][NEUTRAL] 2 years.
[CUSTOMER][NEUTRAL] Two years they kept denying claims. I kept getting things for $25,000 from the hospital and I'm like, you guys are crazy. Like I, and so we had to get on a recorded call with my husband's insurance and my insurance company because they outsource, I'm pretty sure Aetna does to the [PII].
[AGENT][POSITIVE] Oh, wow.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] And like I, it was very frustrating. I'm like you guys aren't giving me anyone with Aetna to actually like work this out with you guys are call center, you know, you know what I mean like it just, so they kept denying it and kept denying it and it wasn't until I got one really good customer service person who's like let's call his insurance and let's get on a recorded line and.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, it was just crazy. It was crazy.
[AGENT][NEUTRAL] So when you, like when you call and you were speaking, speaking to the Philippines, what time of day were you calling?
[CUSTOMER][NEUTRAL] I like normal hours. So we actually, my company used to outsource to the [PII] and what they did was a lot of those people would work overnight, like their nighttime would be our, our daytime. So a lot of those people would work at night.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Like night shift, yeah.
[AGENT][NEUTRAL] OK. OK. All right.
[CUSTOMER][NEUTRAL] So, I know a lot of background information, you're probably like, uh.
[AGENT][NEUTRAL] Well, I asked that because with one with with our um.
[AGENT][NEUTRAL] Phone carrier, it depends on what time of day I call that I get someone that's in the [PII] versus you know outside that's why I was asking the better time to call with your situations.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, it's
[CUSTOMER][NEUTRAL] Yeah, I think it just depends like I think Aetna, their entire call center, from my understanding because I would call during the day. I'm pretty sure all of it, uh, yeah, I think they're all fully outsourced, um, which was kind of frustrating because
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It's outsourced.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I just don't think they understood the full ins and outs like of course they get training, but.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Right, kind of.
[CUSTOMER][NEUTRAL] Yeah, and I don't think obviously there's a like actual Aetna employee with them to ask questions, you know?
[AGENT][NEUTRAL] I, exactly, yes, I know what you mean.
[CUSTOMER][NEUTRAL] So, yeah.
[AGENT][POSITIVE] So you're on the right.
[CUSTOMER][NEUTRAL] Nothing against outsourcing, but yeah.
[AGENT][POSITIVE] Oh yeah, I know. So it sounds like you're on the right track. Call your provider back and get the diagnosis code.
[AGENT][NEUTRAL] And then upload it um.
[CUSTOMER][NEUTRAL] OK
[AGENT][POSITIVE] And then you'll be good to go.
[CUSTOMER][NEUTRAL] OK, perfect. So just a quick reiteration, so the ER visit that was strictly an ER visit on [PII] for JD, that one would probably not be covered because he was not admitted, is that correct?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEGATIVE] Incorrect because you have an outpatient benefit as well.
[CUSTOMER][NEUTRAL] Oh, OK, so I'll submit both of those and I need ICD 10s and CPT codes.
[AGENT][NEUTRAL] You can just ask, so, are you calling the hospital for the ER visit?
[CUSTOMER][NEUTRAL] I try, well.
[CUSTOMER][NEGATIVE] I sent a thing through and they did not give me ICD 10s. I saw CPT codes on there, but I did not, so I'm gonna have to call them again because now they're doing all this documentation through a portal and I just need to scrounge up a phone number because it's super frustrating. I hate when I can't talk to someone, so, um.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, so I'm gonna have to probably call them for an itemized thing with both of those codes on there. Do you have any advice for me?
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Well, I was asking, so with the hospital, um,
[AGENT][NEUTRAL] You could request the UBO4 form that's the hospital bill for your inpatient. It includes everything on there.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then
[CUSTOMER][NEUTRAL] OK, so UB04 form.
[AGENT][NEUTRAL] Uh, university, Bobby, 04.
[AGENT][NEUTRAL] That's for any
[CUSTOMER][NEUTRAL] University, oh, like you're OK, you're spelling it out.
[AGENT][NEUTRAL] You
[AGENT][NEUTRAL] You
[AGENT][NEUTRAL] Acronym, I'm sorry, UB.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I was writing that down. I like I was about to call and be like university bumping.
[AGENT][NEUTRAL] I gotta stop doing that because you're not the first person that said, OK, wait a minute.
[CUSTOMER][NEUTRAL] So it's OK.
[CUSTOMER][POSITIVE] That's so funny. OK. UB 04 form, so call them for that. I'm gonna call it for JD and for [PII] because [PII] was born in [PII] and they still said I have 3000 for him too to claim, um.
[CUSTOMER][NEUTRAL] So yes, I will go ahead and do that.
[AGENT][NEUTRAL] Mhm. And then for the emergency room charge at the hospital, you'll need the same form.
[CUSTOMER][NEUTRAL] OK, so the ER, so if it's the same hospital for both, don't you think both of them would be on that form if I.
[CUSTOMER][NEUTRAL] But probably different dates of service that's why.
[AGENT][NEUTRAL] You know, it's probably separate. It's two separate. It'll be because the patients are different, so they'll, they'll, they have two separate forms, itemized bills, I mean.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] OK perfect I will do that.
[CUSTOMER][POSITIVE] OK, well thank you so much I really appreciate it.
[AGENT][NEUTRAL] Oh, you're welcome. Any other questions I can help with, Ms. [PII]?
[CUSTOMER][POSITIVE] No, I'm good thank you so much.
[AGENT][POSITIVE] OK, thank you for calling APL. Have a good day.
[CUSTOMER][NEUTRAL] You too bye.
[AGENT][NEUTRAL] Bye bye.