AccountId: 011433970860
ContactId: 6230ff09-3c63-489e-84bd-7267c9cf4a02
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 2089350 ms
Total Talk Time (AGENT): 1286035 ms
Total Talk Time (CUSTOMER): 628742 ms
Interruptions: 6
Overall Sentiment: AGENT=0.3, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/25/6230ff09-3c63-489e-84bd-7267c9cf4a02_20250225T17:12_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey [PII], I have an insured on the phone calling about a claim um her claims that were processed where we are requesting additional information and I tried to explain that we were needing like medical notes or records or additional documents for her claim, and she just wanted to speak with an examiner.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, what's the policy number?
[CUSTOMER][NEUTRAL] 214501-1
[AGENT][NEUTRAL] OK, give me just one second to get over there.
[AGENT][NEUTRAL] Um, is it the most recent ones that were done in December?
[CUSTOMER][NEUTRAL] Uh, yeah, the ones that, uh, it's for her part two, and it's uh claim number ending in 44 and 46.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] OK, so it's for part 2.
[AGENT][NEUTRAL] 44 0 OK alright let's see.
[AGENT][NEUTRAL] Uh.
[AGENT][NEUTRAL] Supporting documentation.
[AGENT][NEUTRAL] Oh, so what do we get?
[AGENT][NEUTRAL] I know.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I'm getting these claims pulled up so I can see what we have versus what we need.
[AGENT][NEUTRAL] OK, I have those claims pulled up.
[CUSTOMER][POSITIVE] Awesome sauce I appreciate you.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] All right, bye.
[AGENT][NEUTRAL] All right, bye.
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] Hi.
[AGENT][NEUTRAL] Hi, is this [PII]?
[CUSTOMER][NEUTRAL] It is.
[AGENT][NEUTRAL] Hey [PII], this is [PII]. I'm with the claims department how are you?
[CUSTOMER][POSITIVE] Good how are you?
[AGENT][NEUTRAL] Good, um, so, uh, I understand that you have some questions about two claims that we processed requesting additional information.
[CUSTOMER][NEUTRAL] Yeah, what additional information do you need when I, when I submitted the results from or the discharge summary from both the immediate care and the emergency department and also screenshots, uh, X-ray results?
[AGENT][POSITIVE] OK, uh, let me look through what all we have so I can get a better idea because that's a good question.
[AGENT][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] I submitted the claim form, I submitted the discharge summary. I submitted a screenshot of the X-ray of my cervical spine after I fell on ice in my driveway, which I have a video of, and
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Oh gosh.
[CUSTOMER][NEUTRAL] I got an X-ray of my cervical spine because I was having numbness and tingling and neck and back pain, and they diagnosed me with cervical radiculopathy and I have a spine referral.
[CUSTOMER][NEUTRAL] And that was
[CUSTOMER][NEUTRAL] Kind of at the big, I think that was January maybe? Yeah, the end of January and then the middle of February.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I had a syncopean fall at my home where I was unconscious and I got transported to the emergency department. Got a CT of my head, X-ray of my hip because I hurt my hip. And uh the X-ray was inconclusive, so they did a CT of my hip.
[CUSTOMER][NEUTRAL] And I submitted all of the discharge summary from that.
[AGENT][NEUTRAL] Oh gosh.
[CUSTOMER][NEUTRAL] So I'm not sure what else I need.
[AGENT][POSITIVE] Yeah, that is so much, Ms. [PII]. Goodness.
[AGENT][NEUTRAL] Are you OK? Let me just ask that. Are you OK?
[CUSTOMER][NEUTRAL] And
[CUSTOMER][POSITIVE] I'm doing OK. I'm doing OK now. I just, yeah, I just, a little, it's still taking a couple days, a week or two to kinda like get back to normal, but.
[AGENT][POSITIVE] For sure. Goodness.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So, I looked at the medical records from
[AGENT][NEUTRAL] Believe it was
[AGENT][NEUTRAL] Mm, which one was this one? Uh, [PII].
[CUSTOMER][NEUTRAL] That was the immediate care.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] It only has an indication of pain. There's not an actual diagnosis there for you. Um.
[AGENT][NEUTRAL] Give me just a second.
[CUSTOMER][NEUTRAL] Are you seeing, because I'm looking at it too, are you seeing more than one page? Because it's like 1, there's 6 pages of the discharge summary.
[AGENT][NEUTRAL] Yes ma'am, is there a particular page that I'm not mhm that I'm not looking at?
[CUSTOMER][NEUTRAL] You can see all 6
[CUSTOMER][NEUTRAL] Um, see, I'm going back here.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Just
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Well, it says read the attached information for surgical radiculopathy. I don't know if there's gonna be a diagnosis on this discharge paperwork.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] I don't even have access to their notes.
[AGENT][NEUTRAL] Oh, really? That's odd.
[CUSTOMER][NEUTRAL] Through like my chart or anything.
[AGENT][NEUTRAL] Huh, that's weird.
[CUSTOMER][NEUTRAL] It just says view after visit summary. I have a, a note from the nurse at Elmhurst Hospital, but not the doctor's note.
[AGENT][NEUTRAL] OK, so that.
[CUSTOMER][NEUTRAL] Oh wait.
[AGENT][NEUTRAL] Diagnosis. So basically, like, because of the fall, you
[AGENT][NEUTRAL] Like your spine compressed or whatever. And that's pinching off nerves and stuff, right?
[CUSTOMER][NEUTRAL] Oh, you know what I do?
[AGENT][NEUTRAL] Am I understanding that correctly?
[CUSTOMER][NEUTRAL] So that's the immediate care, that, yeah, if we're talking about the immediate care one, yes, that's.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK. I wanted to make sure I was understanding that diagnosis correctly. OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so let me look in those notes because.
[AGENT][NEUTRAL] I would
[AGENT][NEUTRAL] I would say that that diagnosis.
[AGENT][NEUTRAL] In addition to the fall, I just need to find that.
[AGENT][NEUTRAL] Because I know obviously falling like that trauma can cause obviously that compression.
[AGENT][NEUTRAL] So I'm trying to just find in the notes.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] If it has that specifically so that I can say, oh, here we go, like, this is it, this is what this diagnosis is. Can we, can we reevaluate? Um my system's being so slow too.
[CUSTOMER][NEUTRAL] I don't know
[AGENT][NEGATIVE] Oh come on.
[AGENT][NEUTRAL] I'm sorry, it is just sitting here spinning waiting to load. OK, there it goes.
[CUSTOMER][NEUTRAL] No, that's OK.
[CUSTOMER][NEUTRAL] And I, I.
[CUSTOMER][NEUTRAL] Know that you're not looking at this one right now. The one that was, see, in a, in a second I'll come see you, OK, um, the, the actual emergency department hospital visit one I actually found the doctor's not no you may not.
[CUSTOMER][NEUTRAL] Oh God.
[AGENT][NEUTRAL] So my question about that one is, I know that you injured your hip and you hit your head and all of that.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Did they have an explanation for why you fainted?
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] It was syncope. I'm reading what they, they put in their notes right here. Syncope and collapse.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Contusion to right hip, blunt head, uh, blunt head injury, and nausea, vomiting, diarrhea.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] We were all sick at that time.
[AGENT][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] And I like synopized from being like, either dehydrated or from having nausea, vomiting, and diarrhea all at the same time taking care of our entire family.
[AGENT][NEGATIVE] Gotcha. Yeah.
[CUSTOMER][NEUTRAL] And I had got up in the middle of the night and I synopized, hit my head, hit my hip.
[CUSTOMER][POSITIVE] And it was transported to the emergency department with an ambulance. I haven't even gotten that, but I was gonna submit that as well because I know that there's like some things I can include that.
[AGENT][NEUTRAL] OK, so I will let you know for that one.
[CUSTOMER][NEUTRAL] It's like an ambulance.
[AGENT][NEUTRAL] Because you were sick and it's likely dehydration for accident, the policy definition, obviously, you were injured, so the injuries would meet obviously an accidental injury. However, per your policy definition, it states that it has to be free of disease or bodily infirmity.
[AGENT][NEUTRAL] So because the collapse and subsequent injury was the result of dehydration, sickness, whatever the, whatever it may be.
[AGENT][POSITIVE] Just putting it out there on us for you. That one likely.
[AGENT][NEGATIVE] Will not be payable only because it wasn't due to like this other one where you slipped and fell and injured your spine and had that compression.
[AGENT][NEGATIVE] This one was, you were sick and that caused the injury. You were dehydrated, all of that. So, that one's, that one's gonna be
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Um, and you can
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] Less likely. I don't wanna say it's not, but that one's less likely, um, just because of the, the sickness that was involved that kind of resulted in all of that. Um, the other one though,
[CUSTOMER][NEUTRAL] I'm like yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I see.
[AGENT][NEUTRAL] I feel like.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I'm gonna holla because I do see read the attached information and it has that.
[AGENT][NEUTRAL] Diagnosis.
[AGENT][NEUTRAL] And it also has that you were.
[AGENT][NEUTRAL] Refer to the spinal surgeon.
[AGENT][NEUTRAL] I will go ahead and tell you what I'm gonna do is that one I'm gonna see if someone else will look at and review to see if there's any way with that information we can move forward um but in the meantime until I'm able to give you a call back um if you can obtain an itemized bill that has your like actual diagnosis codes.
[CUSTOMER][NEUTRAL] What did you say?
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] Um, that if I had to guess because we have records, if I had to guess that's what, because there's not a note, um, that is what they, the examiner is wanting for this particular claim is a, a bill that indicates or a physical diagnosis code on some type of billing or.
[AGENT][NEUTRAL] Something from your physician. Um, like I said, I do see that the cervical, um,
[AGENT][NEUTRAL] Compression has
[CUSTOMER][NEUTRAL] Ridiculopathy, yeah.
[AGENT][NEUTRAL] Yeah, that one's a hard one for me. I'm gonna be honest.
[CUSTOMER][NEUTRAL] That's OK.
[AGENT][NEUTRAL] Um, that, that all of the information is here. Like I said, I can see that you were referred to the spinal surgeon. So I am going to see if we can get that, um.
[AGENT][NEUTRAL] Kind of looked at, possibly even reconsidered.
[AGENT][NEUTRAL] But in the meantime, while you're waiting to hear back from me from that review, um,
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] So I'm looking at the bill right now from the Medicare. I'm not seeing any like diagnosing codes. It just says state of service, the provider name.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Like Northwestern Immediate care pretty much and it's just an office outpatient established 30 minutes.
[CUSTOMER][NEUTRAL] Like charge.
[AGENT][NEUTRAL] Hm.
[CUSTOMER][POSITIVE] See you later. I'm just big of it.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Well, hello there. I mean, I can see if I can get something from my
[CUSTOMER][NEUTRAL] Blue Cross Blue Shield.
[AGENT][NEUTRAL] Yeah, and, and truthfully sometimes I actually just had an insured call with a similar issue the other day because we didn't have like the codes that we needed hers was procedure codes, but anyways, nonetheless it was codes and she was able to log in to her major medical and view her EOB and it gave her an alternate view like with what was billed by the physician. I don't know if that's an option. I don't even know if Blue Cross offers that truthfully.
[CUSTOMER][NEUTRAL] And how they
[CUSTOMER][NEUTRAL] It's so
[AGENT][NEUTRAL] Um, I have Blue Cross and I don't know that.
[AGENT][NEUTRAL] But um that may be easier than trying to get in touch with them and get a bill and get it sent and I know that can be a lot um so like I said what I'm gonna do is I'm going to see if they'll look at this and maybe consider it but until you hear back from me, see if you can get go ahead and try for both of these bills um to see if there's anything out there from Blue Cross or.
[AGENT][NEUTRAL] Um, if you can even just contact this, I know with the ER that's gonna be harder, maybe see if Blue Cross has it first, um, but if not, um.
[AGENT][NEGATIVE] Maybe the urgent care would be easier to get something from that has diagnosis codes. I know that that ER is gonna be so difficult, um.
[AGENT][NEUTRAL] Because you're gonna have to like
[AGENT][NEUTRAL] Talk to all kinds of people just to get.
[AGENT][POSITIVE] Even remotely close to an answer.
[CUSTOMER][NEUTRAL] So you guys are just looking for DOB?
[AGENT][NEUTRAL] And
[AGENT][NEGATIVE] No, not necessarily the EOB. So what, what is being given, they didn't actually come out.
[AGENT][NEUTRAL] And give you a diagnosis. The reason why the one from the urgent care was requesting more information is because they only indicated that they saw you for pain. But if you have a physical injury diagnosis, they did not indicate that here. They just
[AGENT][NEUTRAL] They, they alluded to it, but they didn't say final diagnosis is this. And we're referring you to, to the, you know, spinal surgeon for this. Um, and so, we can assume
[AGENT][NEUTRAL] But in insurance, sometimes that doesn't do you very much good, not just as a company, just as a whole. Um, so,
[AGENT][NEUTRAL] That's the biggest thing on that one like I can kind of assume that that's what's going on here obviously you were referred out but they didn't come out and just give you a diagnosis so it's really the diagnosis codes from your provider sometimes the EOB does offer that and that that's what we need.
[AGENT][NEUTRAL] So if the EOB has that you definitely can, you definitely can submit that and you know we'll see that the diagnosis codes are listed um but that's what we need for both dates is the diagnosis codes to be 100% certain that we can move forward as an accident policy like I said, the one with the ER.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um,
[AGENT][MIXED] I want to be optimistic, but with you all being sick and going in due to possible dehydration because of the diarrhea and the vomiting and all the sickness, God bless you. Um,
[AGENT][NEUTRAL] That is again, that one's just less likely because of the policy definition of what qualifies.
[AGENT][NEUTRAL] For an accidental injury.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEGATIVE] I wouldn't even be able to submit the ambulance ride due to this for the injury. I'm needing to use an ambulance because I can't drive myself to the emergency department for syncope.
[AGENT][NEUTRAL] So let's see.
[AGENT][NEUTRAL] I'm gonna, I'm gonna, before I even respond, I'm gonna pull up your policy and kind of read what that covers to make sure that there's not any verbiage in there that exclude it, uh, excludes it. Um, I want to say.
[AGENT][NEUTRAL] That it has to be a covered accident and a covered accident has to be due to the accidental bodily injury, which again, because of possible sickness diagnosis, that may not, it, it's like it, it would all build up to not being paid. But I want to confirm.
[AGENT][NEUTRAL] The verbiage in your policy before I say no, you know, like because I really don't wanna say no.
[AGENT][NEUTRAL] Um, let's see, let me get up further.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Because we submitted something similar for my daughter 2 years ago when she syncopized and fell and she actually had like, she either like bigled or something.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So then they found that her blood sugar was like super low, but everything, we got everything covered then. I don't know if it was just because of.
[AGENT][POSITIVE] Oh wow.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] You know, that's why we found out that she, that happened to her, but
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, let me get to that definition. Let's see.
[AGENT][NEUTRAL] OK, ambulance, um.
[AGENT][NEUTRAL] Yeah, for a covered accident and then when we go to covered accident.
[AGENT][NEUTRAL] Where did it go?
[AGENT][NEUTRAL] Mm.
[AGENT][NEGATIVE] I feel like this policy is all over the place sometimes with the definitions.
[AGENT][NEUTRAL] Claims provisions.
[AGENT][NEUTRAL] Definitions OK.
[AGENT][NEUTRAL] So.
[AGENT][NEUTRAL] Covered accident is a sudden unforeseeable and unexpected event that causes injury to a covered person wholly independent of disease, bodily infirmity, illness, infection, or any other abnormal physical condition.
[AGENT][NEUTRAL] So that is the policy definition of covered accident and any benefits payable under this policy. Well, I don't wanna say any, most of them, I haven't read all of them, most of them though are payable when due to a covered accident.
[AGENT][NEUTRAL] So, ambulance, X-rays, urgent care, surgery, hospital stay, ER, any uh anything that's listed on your schedule.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Except for
[AGENT][NEUTRAL] Maybe, I mean, obviously the accident screening, that doesn't have to be due to an accident. That's for the prevention of an accident. Um, but all of the others because it's strictly an accident policy and not accident and sickness, um, it will have to be for a covered accident.
[AGENT][NEUTRAL] But like I said, I don't know what they diagnosed you with specifically. I just know that they noted that you had.
[AGENT][NEGATIVE] The syncope and the diarrhea and the vomiting.
[AGENT][NEUTRAL] If they did not diagnose you with a sickness and the only thing they have on there is your injuries, then we're looking at a higher chance of of payable claim.
[AGENT][NEUTRAL] So without those diagnosis, you know, and that's why I'm like, if they, if they indicated it was due to sickness, that's where it's less likely. But if they don't feel like you synopize because of sickness and it was just kind of like, I mean,
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] You know, kind of like a, we don't really know, she just kind of passed out and then she hurt herself, then it, it has a higher probability of, of payment, but I can't really tell because I don't know exactly what they're saying your diagnosis. They're just kind of indicating why you were there. I know it says diagnosis syncope and collapse and then the nausea and all of that stuff, but.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEGATIVE] That doesn't really give us any reasoning, you know what I'm saying? Because they did all your lab tests. How did your lab test come back? Like was your COVID and everything?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][POSITIVE] COVID was fine. It was, I was positive for norovirus.
[AGENT][POSITIVE] Oh wow.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] Goodness. OK.
[CUSTOMER][NEGATIVE] So yeah, COVID flu, RSV were all negative.
[AGENT][NEUTRAL] I am.
[CUSTOMER][NEUTRAL] They weren't even gonna do a school study and I asked for one because of it being like,
[CUSTOMER][POSITIVE] Kind of going around my family and I didn't have, and this is a wild thing is I
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] I thought I was like the sole survivor. I was up taking care of all my family and everything all day long. And then like I got up at, and I got up at [PII] and had this syncopa slash fall. And then after that, I started to have diarrhea. I never vomited once in the entire time and I had one episode of diarrhea.
[AGENT][NEUTRAL] As moms do, yes.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEGATIVE] That like I singleized and fell.
[CUSTOMER][NEUTRAL] Before I started having like norovirus, yeah, but that's not that.
[AGENT][NEUTRAL] Before all of that.
[AGENT][NEUTRAL] Oh, so it.
[AGENT][NEUTRAL] So now I'm wondering if if that's the case if like.
[AGENT][NEUTRAL] The head injury or whatever. It doesn't. You're right, it doesn't, but I'm wondering if there is some
[CUSTOMER][NEUTRAL] It doesn't look like it's charted that way though.
[AGENT][NEUTRAL] possibility that there could be that the head injury or, you know, the, the collapse by itself regardless of the head injury is what
[AGENT][NEGATIVE] caused you to start vomiting. Cause I mean, my pain response is vomiting. So if I'm hurting, and if you hurt your hip and your head and your spine's already hurting like all the things,
[AGENT][NEUTRAL] Then I'm wondering if that was kind of your pain response was just your body like get it out, get all the things out.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh, I don't know. I, I mean, I did have diarrhea like shortly, shortly thereafter that they ended up testing and said that it came back positive for Noro, so I don't know, like I just didn't know that it needed to be, it, it mattered that.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] You still can't get injured if you're sick to not have coverage, like just from a virus or something like that. I, I
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah, so
[AGENT][NEUTRAL] Right, so that's.
[CUSTOMER][NEUTRAL] I guess if you're like, chronically sick and there's things that can happen, but like what if you do have some sort of
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] Chronic sickness that it's always like lupus or fibromyalgia where they're gonna be like, oh well, you have this, you can never get injured in your life.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] Right, no, I completely understand, completely understand, um, I don't disagree with you. I, I don't, um.
[AGENT][POSITIVE] Just, I'm really, really hoping that.
[CUSTOMER][NEUTRAL] I guess that's kind of how it is.
[AGENT][NEUTRAL] Oh man, do we have a signed HIPAA release for you?
[AGENT][NEUTRAL] Did you sign that HIPAA release? Do you know?
[CUSTOMER][NEUTRAL] Um, I
[CUSTOMER][NEUTRAL] Sure
[CUSTOMER][NEUTRAL] I'm not sure I could, I could have.
[AGENT][NEUTRAL] Because I'm wondering instead of you.
[AGENT][NEUTRAL] Trying to, I mean, if you, if you still want to see if you can obtain the diagnosis codes from your insurance company and get those uploaded, definitely do that um but I'm wondering if we have a HIPAA release if we could just reach out for medical records because the diagnosis codes may not be how their notes read, you know what I'm saying? Like their notes may end or their, their diagnosis may indicate sickness, but their notes may say.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] You know this woman fell, she passed out, she fell, she hit her head, she hurt her hip, and then this, this, this and this started happening instead of looking like the reverse on the billing.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] I mean the charting.
[AGENT][NEUTRAL] That's what I'm wondering.
[CUSTOMER][NEUTRAL] I'm reading the charting right now. It doesn't sound that way because it does say that like, I went and got up to use the bathroom and sync aize in the bathroom.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So that's probably where they're gonna say like I started getting sick then, like in the bathroom at the same time and I like syncoized. But I also noted here and it says that she's had 4 days of a, of a heavy period. So it's like
[AGENT][NEUTRAL] Mm.
[AGENT][POSITIVE] So like all the right, it's like all the things were going on all at once. Oh my goodness.
[CUSTOMER][NEUTRAL] It could be so many different
[CUSTOMER][NEUTRAL] 56.
[CUSTOMER][NEUTRAL] Yeah, so,
[AGENT][NEUTRAL] And you said you had those records?
[CUSTOMER][NEUTRAL] Ah.
[CUSTOMER][NEUTRAL] I have their notes and I'm reading that, yes, I found the doctor's the provider's notes and it says.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Yeah, they, her entire family has been sick.
[CUSTOMER][NEGATIVE] I started was started the diarrhea, and she was in the bathroom, turned around, felt like she had a vomit, which I never did. And
[AGENT][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Her husband found her on the floor and that's.
[CUSTOMER][NEUTRAL] Pretty much how it happened.
[AGENT][NEUTRAL] I mean, it says your family has been sick though it doesn't say you have, so.
[CUSTOMER][NEUTRAL] So it's like, it feels.
[CUSTOMER][NEUTRAL] What did you say?
[AGENT][NEUTRAL] I said it says it's that your family had been sick though. It doesn't, it doesn't indicate that you were in that note. You know what I'm saying?
[AGENT][POSITIVE] Oh, I don't know that's a tough one. OK, so here's what I'm gonna do. I do have a signed hip release for you.
[AGENT][NEUTRAL] I'm gonna reach out to these two facilities for medical records.
[CUSTOMER][NEUTRAL] Ah.
[AGENT][NEUTRAL] Um, for each date.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, including all the things, any lab tests, any admin discharge, like all the things so that we can get a very clear picture of what they are charting.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] On all aspects including your lab work and you know, all the things.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And then in the meantime,
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um, see if you can access your, um,
[AGENT][NEUTRAL] Your EOB and if it will give you the option to view the codes so that you can submit maybe a screenshot or something of that that shows your diagnosis codes for those dates.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then that way we're kind of attacking it from both ends. You can see if you can get the actual codes. I'll see if I can get physical records because I feel like.
[AGENT][NEUTRAL] It's one, it's so up in the air on that one where you went to the ER and there's so much more that you may.
[AGENT][NEUTRAL] Need covered on that one so I don't want to just assume oh you were sick like I said and based on your policy that that likely wouldn't be payable because there could be so much more to it and it could go either way it's so tough to know um on the other one I feel like their notes are gonna indicate an injury we just need we just need more in more detailed information I guess.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Yeah, cause
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] Yeah, so I found this note. It says patient with nausea, vomiting, diarrhea.
[CUSTOMER][NEUTRAL] Suspected viral GI illness, her family has similar. Patients provided fluids, nausea medication, Toradol, pain medication, muscle relax, or muscle stiffness after fall.
[CUSTOMER][NEUTRAL] Um, and then I got that, it says like the.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Like scans and X-rays that I received while I was there.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] That's wild, yeah.
[AGENT][POSITIVE] It is wild because like I said because it's like it's still.
[CUSTOMER][NEGATIVE] I mean, nausea, mi, nausea, vomiting, diarrhea, like everyone charts that all three of them together.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] You know, like it, I had vomiting, so that's incorrect, but
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah, um.
[AGENT][NEUTRAL] Let's let's attack this from both sides. I'm, I'm gonna do the part of getting the physical records it may take some time, um, but that's gonna be.
[AGENT][NEUTRAL] It's gonna be so much more detailed than just a bill.
[AGENT][NEUTRAL] On what we may be able to do or not do. Um, again, I feel like the one from the urgent care, there's, there's a higher likelihood there just because you had spinal compression from the uh fall. I don't, don't feel like we have a ton to worry about there. I feel like that one, we just need more detailed information. Like I said, the one with the ER I'm still up in the air about, I don't know.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] I don't know which way that one's gonna go, um, maybe the combination of, of diagnosis codes and records to kind of view it all together will help us. Um, it may me longer to get records because we do ask that you allow us 30 days. It doesn't always take that long. Some hospitals respond faster, um, but it, it could, so, um.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] But
[AGENT][NEUTRAL] Let me do that on my side. If you are able to obtain the diagnosis codes, get those submitted and we'll go ahead and review those. If you get another denial for either one of them, just know that the records are coming, don't lose hope yet.
[AGENT][NEUTRAL] Um, and, and we're gonna see what those say as well because we may be able to go back once we receive records and say, oh, OK, actually this was or whatever the case, you know, maybe we didn't pay something that we should have or whatever so let's.
[AGENT][POSITIVE] Let's kind of both do that and see hopefully we can get one or both of these paid at least in the in a short time frame so you don't have to wait.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] That's, I appreciate you uh reaching out.
[AGENT][POSITIVE] No problem at all, no problem at all.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] So if you're gonna be getting all the medical records, you don't need me to get those EOBs.
[AGENT][NEUTRAL] No, you don't have to. Um, the biggest thing, like I said, is if you want to go ahead and see if diagnosis codes are listed on either one and if there is any type of injury diagnosis specifically on the urgent care one.
[AGENT][NEUTRAL] Um, then I might be tempted to go ahead and upload that if it were me, just because having to wait on records, that's just going to, you know, that's just gonna take time, whereas if you have an injury diagnosis, um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Then we're gonna
[AGENT][NEUTRAL] We're gonna be able to evaluate that faster because it's coming from you, um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] But the, yeah, but the records themselves, um, I'll still go ahead and request them because like I said, that, that diagnosis could come back as being
[CUSTOMER][NEUTRAL] I, yeah.
[AGENT][NEUTRAL] Not necessarily accident related even though we know you hadn't like you fail and that it can be due to trauma. That's why I want the records because just because it's not necessarily a
[AGENT][NEUTRAL] Injury or trauma or accident related diagnosis code doesn't mean that it wasn't the result of one, you know what I'm saying? And a lot of times, the records are gonna be a little more clear as to.
[AGENT][NEUTRAL] What, sometimes the diagnosis just isn't enough. And I feel like in these situations.
[AGENT][NEUTRAL] They're unique in that we know accidents happen.
[AGENT][NEUTRAL] Can we move forward with payments regardless of.
[AGENT][NEUTRAL] Maybe some diagnosis codes that would otherwise disqualify these benefits for payment, you know what I'm saying? So.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] So, yeah. So I'm gonna do that if you are able to get them, especially if they have a, uh injury diagnosis. I would, I would go ahead and do that and we'll go ahead and, and review it. But again, if you get another denial saying that maybe it's not covered because of the diagnosis.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Just
[AGENT][NEUTRAL] Oh hold on for me because the records will be coming, they're still gonna be requested regardless of whether you upload anything or not. I'm still going to do that, OK?
[CUSTOMER][POSITIVE] OK, I appreciate it, um.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] No problem at all. Is there anything else I can do for you, Ms. [PII]?
[CUSTOMER][NEUTRAL] Um, what is your name? Should I be trying to see if I can get in contact with you again, or would you be putting in notes so that I can just talk to anybody?
[AGENT][NEUTRAL] Um, so I will put in a note so you can talk to anybody if you want to talk to me you can request me, that's fine. I'm, I'm here all day every day unless there's a circumstance otherwise, so, um, you can. My name is [PII], last initial [PII] and I'm in the claims department.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] What is your name?
[CUSTOMER][POSITIVE] [PII], I think you've helped me before.
[AGENT][NEUTRAL] I might have. I feel like I recognize your name, so I was just like, hang on a second.
[CUSTOMER][NEUTRAL] To be honest with you.
[CUSTOMER][NEUTRAL] I, I, honestly, I think I have, have, you have helped me before and I have called back and I have like asked for you, and I think I don't know other muggins, I'm not sure, but I'm p[PII] sure that I might have been talked to you previously about other, other stuff.
[AGENT][POSITIVE] Quite possibly, quite possibly. Well, I'm here to assist again if you need it, Ms. [PII].
[CUSTOMER][POSITIVE] Alright, thank you very much and I will um get that stuff on my end hopefully over to you soon.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] OK alright and I will go ahead and try to get that record request um out hopefully before the end of today I'm gonna have to reach out to them and see if they have like a fax number or an email or something we can send the request to.
[CUSTOMER][POSITIVE] Sounds great. Thank you very much.
[AGENT][POSITIVE] OK. You're welcome. Have a good evening.
[CUSTOMER][NEUTRAL] You too. Bye-bye.
[AGENT][NEUTRAL] All right. Bye-bye.