AccountId: 011433970860
ContactId: 624a6fac-9063-42af-9eb5-65803f3e79a5
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1069339 ms
Total Talk Time (AGENT): 362650 ms
Total Talk Time (CUSTOMER): 525897 ms
Interruptions: 7
Overall Sentiment: AGENT=0.5, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/23/624a6fac-9063-42af-9eb5-65803f3e79a5_20250523T22:00_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Uh yes, my name is [PII], and I was calling um regarding a uh a bill that was denied from January.
[AGENT][NEUTRAL] OK, so are we just needing clarification regarding that claim?
[CUSTOMER][NEUTRAL] It's every other ones just instant pay.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, yeah, I could take a look at that for you. uh [PII], can I get a good call back number from you first in case we're disconnected?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes, yeah, 662.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] 242
[CUSTOMER][NEUTRAL] 0423.
[AGENT][NEUTRAL] OK and then do you have your policy number?
[CUSTOMER][NEUTRAL] I do.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It is 009.
[CUSTOMER][NEUTRAL] 82081
[AGENT][NEUTRAL] OK thank you one moment.
[AGENT][NEUTRAL] Alright, and I'm just gonna verify some information really quick uh [PII], can I get your date of birth please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you and then can I get your mailing address?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Perfect. The last thing I need is the email address we've got on file for you. uh, looks like it is a Hotmail account.
[CUSTOMER][NEUTRAL] Yeah, [PII].
[AGENT][NEUTRAL] OK, thanks for verifying all of that. OK, do you have the uh claim number uh that this is regarding?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Um, let me see.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] See if I can use your details. Uh, don't I have the date of service just not the claim number.
[AGENT][NEUTRAL] That's OK. I can use the data service.
[CUSTOMER][NEUTRAL] Alright, date of service is [PII].
[AGENT][NEUTRAL] [PII]. OK, one moment please.
[AGENT][NEUTRAL] There we are, OK.
[AGENT][NEUTRAL] Was this from a Baptist Memorial Hospital?
[CUSTOMER][NEUTRAL] Yes
[AGENT][NEUTRAL] OK, thank you one moment, let's take a look.
[CUSTOMER][NEUTRAL] It
[AGENT][NEUTRAL] OK, so according to these notes here, [PII], it states that this is not a covered loss under this policy and that the benefits of course are only payable as outlined in the schedule of benefits. So give me just a moment.
[CUSTOMER][NEUTRAL] But it is.
[AGENT][NEUTRAL] I can only see like a surface level sure so give me just a minute let me take a deeper look.
[CUSTOMER][NEUTRAL] OK, because it was.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Because that is, that is quite vague.
[CUSTOMER][POSITIVE] OK, you're good.
[CUSTOMER][NEUTRAL] Well, and then I will tell you this.
[CUSTOMER][NEUTRAL] This is for my infusion and all of the other infusions since that one infusion has been covered.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] Well [PII], let's do this if you don't mind, I'm going to put you on a brief hold and reach out to our claims specialists because again I, I'm just wanna make sure I get proper clarification for you regarding this so we'll take a deeper look alrighty.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] You're, no, you're good. Oh, that's perfectly fine. I'm glad.
[AGENT][NEUTRAL] OK, give me just a moment I'll get right back with you OK?
[CUSTOMER][NEUTRAL] Alright
[CUSTOMER][POSITIVE] Oh, you're fine sounds good.
[AGENT][POSITIVE] Thanks one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hey Ms. [PII], this is [PII] on the care team. How are you today?
[CUSTOMER][POSITIVE] I'm good how are you [PII]?
[AGENT][POSITIVE] Being good ready for this long weekend.
[CUSTOMER][NEUTRAL] I know it.
[AGENT][NEUTRAL] Girl, right, well, I got an insured on the line. He's calling regarding a um Medlink claim and the denial notes simply state that it's not a covered loss um and she stated that there's been multiple claims filed that are identical and she doesn't know what's so different about this one.
[CUSTOMER][NEUTRAL] OK, what's the policy?
[AGENT][NEUTRAL] It is 982-081.
[CUSTOMER][NEUTRAL] OK, um, which claims specifically are we looking at?
[AGENT][NEUTRAL] It is, yes, um, it's uh 355-623-2.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Let's see, it looks like it was.
[CUSTOMER][NEUTRAL] Mm, OK, hang on.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] I think I might know what's going on here but I'm gonna double check.
[CUSTOMER][NEUTRAL] Looks like she was in there for treatment for cancer.
[AGENT][NEUTRAL] Yeah, I think she said it was some kind of infusion.
[CUSTOMER][NEUTRAL] I'm gonna look at her policy and.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I'm gonna look at her policy sir to see.
[CUSTOMER][NEUTRAL] What it says.
[CUSTOMER][NEUTRAL] For outpatient, let's see.
[CUSTOMER][NEUTRAL] Yeah, I don't see cancer treatment included in her outpatients.
[CUSTOMER][NEUTRAL] Let me double check myself.
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Outpatient hospital.
[CUSTOMER][NEGATIVE] Please tell me you can't hear my children in the background.
[AGENT][NEUTRAL] Oh no, I can't. I'm trying not to laugh. I'm sorry, that sounds just like my son.
[AGENT][NEUTRAL] Yeah, but I'm sitting here biting my lip trying not to just start cracking up because it sounds just like my son like.
[CUSTOMER][NEUTRAL] Ah oh.
[CUSTOMER][NEGATIVE] Oh my God, they're so loud.
[AGENT][NEUTRAL] No, it's OK, it's not that bad, trust me, it's just makes me think of my kiddo, that's it just wild as can be.
[CUSTOMER][POSITIVE] Oh my gosh.
[CUSTOMER][NEUTRAL] Uh it's like summer just started, you guys like I need you to simmer.
[AGENT][NEUTRAL] Uh, yeah, this was his last day and he's already I'm like, oh man, it's gonna be a long couple of months.
[CUSTOMER][NEUTRAL] Yep yep, OK, so I don't see treatment for cancer covered in outpatient services so I feel like this was actually denied appropriately however, I would have to review her history to review what's been paid in the past and why it may have been paid then and not paid now um because as far as.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, that's what I was wondering if she had something similar because she said it's paid before but she can didn't give me anything exact and you know I'm not gonna argue with her so it's like mm let's take a look.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Right, so 623-2 that was processed back in January and the claim before that that was paid was like.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Over a year ago.
[CUSTOMER][NEUTRAL] And I don't even see, well, I say it was paid, let's see.
[CUSTOMER][NEUTRAL] 623-2 we paid something after that.
[CUSTOMER][NEUTRAL] Also in a facility, let me see what that one looks like.
[CUSTOMER][NEUTRAL] Because that may be the confusion is like for data service 116.
[AGENT][NEUTRAL] It, yeah.
[CUSTOMER][NEUTRAL] And this was for 19.
[AGENT][NEUTRAL] Oh, yeah, maybe that's what she thought.
[CUSTOMER][NEUTRAL] We pay but.
[CUSTOMER][NEGATIVE] Yeah, like, oh we all paid this one. Why didn't you pay the other one? And that could be that actually 116 shouldn't have been paid.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So let me see.
[CUSTOMER][NEUTRAL] I don't even know what this, oh, that looks like surgery. That may be why.
[CUSTOMER][NEUTRAL] Let's see 36598.
[CUSTOMER][NEUTRAL] Nope, uh, it may be imaging that's also payable in an outpatient setting.
[CUSTOMER][NEUTRAL] That's a contrast material.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEGATIVE] Questionable.
[CUSTOMER][NEUTRAL] Uh, don't know about that one.
[CUSTOMER][NEUTRAL] Yeah, I'm gonna have to look at that one. I'm trying to figure out what the heck may have paid that would cause the confusion because it looks like she's had several, yeah, um.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] That made her think that, right.
[CUSTOMER][NEUTRAL] Like I said, the last thing I see is paid was 35 of 24, so a year ago.
[AGENT][NEUTRAL] Yeah, I think she might have got confused like you said from this most recent one that did take because it is the same facility. It's the, or the same provider rather.
[CUSTOMER][NEUTRAL] And that was paid at 2800.
[CUSTOMER][NEUTRAL] It is the same facility right, but it looks like it's for different services um and the last thing we paid was for.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] 12 of 24.
[CUSTOMER][NEUTRAL] And she had blood work and.
[CUSTOMER][NEGATIVE] It looks like she had several procedures, so she had surgery and anesthesia, she had a hysterectomy like there was all kinds of stuff done on that one so that would have been paid because surgery in an outpatient setting. So I feel like this was denied appropriately. I don't even truly know that the most recent one should have been paid because it doesn't, I don't see anything.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] If it's something related to that, yeah.
[CUSTOMER][NEUTRAL] Yeah, because what was done [PII].
[CUSTOMER][NEUTRAL] It's the contrast injection for evaluation of existing central Venus access device so maybe because it's like.
[CUSTOMER][NEUTRAL] I don't know.
[CUSTOMER][NEUTRAL] Because that would typically be like a surgical top code, but that doesn't, that's not surgery, that's an injection of contrast materials so that is not obviously.
[AGENT][POSITIVE] Girl, you got me.
[CUSTOMER][NEUTRAL] Yeah, so I'm just kinda like, uh, I don't know, um, I'm trying to even figure out.
[CUSTOMER][NEUTRAL] If this was released by the examiner or by.
[CUSTOMER][NEUTRAL] A auditor it was released by the examiner.
[CUSTOMER][NEUTRAL] So, um, let me see what these revenue codes are, is she wanting to talk to me directly or she just wanting like what is she needing from us today?
[AGENT][NEGATIVE] She didn't say exactly. Uh, she wanted to, of course, more clarification as to what that meant or she did well when I read her, of course, that it's saying that it was not a covered loss, that's when she said, but it is, and then she brought up that it paid before and so that's when I was like, I'm not stepping on toes. I will get with someone else.
[CUSTOMER][NEUTRAL] Oh, you know, was it.
[CUSTOMER][NEUTRAL] I can see where she may be saying that because we paid for the 36598 and that revenue code on that on that next claim for 116 and it has a revenue code of 361 and that revenue indicates a minor surgery so operating services and on this claim there's 36593.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And it's the declotting of that same device that we paid for for 116.
[AGENT][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] So it's also indicating it was hidden because all I was seeing was therapy and everything so uh it may be qualifiable honestly because of that one code so if you want to relay to her that I'm gonna have this reviewed.
[AGENT][NEUTRAL] I can.
[AGENT][NEUTRAL] Sir.
[CUSTOMER][NEUTRAL] Um, because that code she may be right, but I don't wanna say yeah you're right, just let her know that we're gonna review it, yeah, and um once I have that reviewed, you know, we're out Monday and nobody else is here so um I will I'm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Yes, OK.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] I probably say like Tuesday or something. I'll, I'll just blame the holiday.
[CUSTOMER][NEUTRAL] Yeah tell her Tuesday because of the holiday at the earliest, but Wednesday could be a possibility so I would say give us until next week to get back to her but we are going to review it.
[AGENT][NEUTRAL] Right, OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Sure, OK, I will let her know, um, do you want her to call back?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes, please.
[AGENT][NEUTRAL] OK, uh, that is [PII].
[CUSTOMER][NEUTRAL] OK, um, the only thing that I, and you don't have to tell her this, but just what I'm thinking is that it does leave responsibility but it's for everything and we may not because that was.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I don't know it may be that we need a more detailed broken down like EOB broken down by charge because we may only be able to pay for that charge. I'll have that's part of the review, so.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] I see.
[AGENT][POSITIVE] Sure, OK, I can just tell her we'll take a deeper look at it, um, and then we'll get back with her. I'll just try to keep it as vague as I can. Alright, well I sure appreciate your help, [PII]. Have a good weekend.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] For sure. OK.
[CUSTOMER][NEUTRAL] Yeah, yeah.
[CUSTOMER][POSITIVE] No problem at all, you too.
[AGENT][NEUTRAL] All right, bye.
[CUSTOMER][NEUTRAL] Alright, bye.
[AGENT][POSITIVE] Alrighty [PII], I am so sorry about that wait are you still with me?
[CUSTOMER][NEUTRAL] Yeah, I'm still here.
[AGENT][NEUTRAL] OK, I apologize that took so long. um, they were doing some deep diving so long story short, um, they are going to of course take a deeper look, um, because I do believe I found, um, the claim in question when you said that it had uh been paid for before.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, I do believe I found it, so we were trying to take a look at that, um, but what they're gonna have to of course do some further research into it to, you know, how it was processed and if it needs to be reprocessed, um, and so I did give her, uh, your callback number, um, most likely because we will be closed on Monday for Memorial Day.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, you should hear back from us on Tuesday if at the latest Wednesday I would say, um, but I, I'd imagine you'd hear back from us on Tuesday regarding this, um, do you want me to, I'm sorry, go ahead, go ahead, I'm sorry.
[CUSTOMER][NEUTRAL] Yeah, that's fine.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Well, and, and let me.
[CUSTOMER][NEUTRAL] I was gonna say, uh, to put, to put some notes in the system, I get infusion every 21 days.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] So every claim, and it's the same medicine.
[CUSTOMER][NEUTRAL] Every claim since the [PII] that one claim every claim since then has been paid.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Well, that's according to the information we have, uh, we haven't, um, the last claim that we paid for you prior to this um that date of service was uh [PII].
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] Yeah and that's it is a bit odd um.
[CUSTOMER][NEGATIVE] Because I haven't got a bill for anything, so.
[AGENT][NEGATIVE] I don't know yeah I'm seeing uh what we've received several but not that we were able to pay anything um different.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] But now, um, do you want me to go ahead and give you this claim number just so you've got it for your records?
[CUSTOMER][NEUTRAL] Yeah, let me get to that.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] I don't want a new one. OK, what's, uh, what's the cloud.
[AGENT][NEUTRAL] That is 35.
[AGENT][NEUTRAL] 56232
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, I
[CUSTOMER][NEGATIVE] The only one I've gotten a bill for.
[AGENT][NEUTRAL] Yeah that's interesting. I'm not sure I mean um we don't ever say what is patient responsibility we always do leave that up to the provider um so it's possible that, you know, yeah.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] So, I don't know.
[CUSTOMER][POSITIVE] All right, it's just what I wanted to know.
[AGENT][NEUTRAL] I'm not sure
[AGENT][POSITIVE] This is an odd one, yes, so we will definitely get back with you as soon as we've got an answer for you, Miss [PII]. Do you have any other questions for me at the moment?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, that's it.
[AGENT][POSITIVE] Alright well thanks for giving us a call and I hope you have a great weekend.
[CUSTOMER][POSITIVE] Thank you. You too.
[AGENT][POSITIVE] Thank you. Bye-bye.
[CUSTOMER][NEUTRAL] Alright bye bye.