AccountId: 011433970860
ContactId: 61266abc-6cd4-492d-aac7-46e3c4097633
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 418579 ms
Total Talk Time (AGENT): 149792 ms
Total Talk Time (CUSTOMER): 140242 ms
Interruptions: 1
Overall Sentiment: AGENT=0, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/24/61266abc-6cd4-492d-aac7-46e3c4097633_20250224T19:15_UTC.wav
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[AGENT][POSITIVE] Good afternoon, thanks for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hey [PII], this is [PII] over on the care team. How are you?
[AGENT][NEUTRAL] Fine, how are you?
[CUSTOMER][NEUTRAL] Doing all right thank you. I have a member on the line wanting to talk to y'all um she submitted a claim for her HI policy it denied as not covering of outpatient surgery. She said that it is inpatient. Um, she did say that you know that she submitted the correct information and all that that shows that it was over 18 hours. Um, I have that information whenever you're ready.
[AGENT][NEUTRAL] Sure, what's the policy number?
[CUSTOMER][NEUTRAL] 2,110,350
[CUSTOMER][NEUTRAL] And it's for a part two, that's who we're speaking with.
[AGENT][NEUTRAL] No, it's 211-035-1.
[CUSTOMER][NEUTRAL] 50.
[AGENT][NEUTRAL] And which claim is it in regards to?
[CUSTOMER][NEUTRAL] So I think she submitted it quite a few times, but I believe the original was uh 356-3361.
[AGENT][NEUTRAL] OK, let me glance and see what we got.
[CUSTOMER][NEUTRAL] I tried looking. I don't see anything with time, but she did say that she submitted that. um, I don't know, there does seem to be some confusion with this because at first she said it was she was there for 32 hours.
[CUSTOMER][NEUTRAL] But then she said that it was from the [PII], so at the most that would have been 24, but.
[AGENT][NEUTRAL] Let's see, on this first document, she only sent the surgeons.
[AGENT][NEUTRAL] Information, let me see on this most recent claim.
[AGENT][NEUTRAL] That was processed on the [PII].
[AGENT][NEUTRAL] OK, OK, so we have the UB, so let me take a look and see what we have here on here if it had any.
[AGENT][NEGATIVE] Yeah, that's why I was denied. Even on the EOB it's outpatient. It doesn't have any observation hours or room and board.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] So in order for us to consider it under inpatient, we need either the admin discharge summary that provides us what time they were admitted on the [PII] and what time they were discharged on the [PII] because the UV doesn't even show that they had a room or any observation hours. So that's why I was denied again as um.
[CUSTOMER][NEUTRAL] Oh,
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right, and I told her that, um,
[CUSTOMER][NEGATIVE] I told her that and she said that was what she had originally sent. That's why I tried looking at this first claim, but even there I couldn't see anything.
[AGENT][NEGATIVE] It doesn't. That's just the surgeon's, that's just the surgeon's information. It doesn't provide us with the time she was admitted or discharged on the [PII] and that's what we're needing.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right, OK. Would you mind explaining that to her?
[AGENT][NEUTRAL] Sure.
[CUSTOMER][POSITIVE] I appreciate it. Are you ready for her now?
[AGENT][NEUTRAL] Yeah, you can send it to me.
[CUSTOMER][POSITIVE] All right thank you bye bye.
[AGENT][NEUTRAL] Claims department, this is [PII].
[CUSTOMER][NEUTRAL] Oh yes, [PII] on the phone with uh [PII], I believe. She was checking on a claim for me.
[AGENT][NEUTRAL] Yes, and she said you have some questions regarding the claim for the 1224 to 122524 data service.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, so on this claim, it looks like we did receive the itemized billing. On the itemized billing, um, it did not indicate that there was any inpatient. It didn't indicate any room charges or any observation hours in the room to indicate that it was inpatient. So in order for us to further review this claim submission, what we will need is the admin discharge date and time in order to further consider this claim.
[CUSTOMER][NEUTRAL] OK, I did tell [PII] that um
[CUSTOMER][NEUTRAL] The first documents that went with the claim.
[CUSTOMER][NEUTRAL] Have all that information.
[AGENT][NEGATIVE] So I'm looking at the first document. It only tells us the date, the dates of [PII] and [PII]. It does not provide us with what time you were admitted on [PII] or discharged on [PII].
[CUSTOMER][NEUTRAL] No, let me, let me show you where it's at.
[AGENT][NEUTRAL] Unless we don't have that document that you're referring to because what I'm looking at is just a coding summary, and it doesn't provide us with the times.
[CUSTOMER][NEUTRAL] And then it went with the ATALI, it went with the claim form.
[CUSTOMER][NEUTRAL] That was sent out along uh on [PII].
[CUSTOMER][NEUTRAL] And it's a record of admission.
[CUSTOMER][NEUTRAL] And on the.
[CUSTOMER][NEUTRAL] It shows.
[CUSTOMER][NEUTRAL] Where it shows the biology is sulfur. It shows the
[CUSTOMER][NEUTRAL] Admission date at [PII] at [PII].
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Discharge day [PII] at [PII].
[AGENT][NEUTRAL] OK, let me look because I'm not locating that document, but let me look through all the documents we received because I'm not seeing that one. So give me one moment. I'm gonna put you on a brief hold. Give me one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Thank you for holding, Ms. [PII]. Yes, I did locate that, so I'll put in a request to get this claim reprocessed.
[CUSTOMER][POSITIVE] OK, thank you very much. I appreciate your help.
[AGENT][POSITIVE] You're welcome. Is there anything else I can assist you with today?
[CUSTOMER][NEUTRAL] No, that would be it.
[AGENT][POSITIVE] OK, well thank you for calling APO you have a good day.
[CUSTOMER][NEUTRAL] You too bye.
[AGENT][POSITIVE] Thank you, bye.