AccountId: 011433970860
ContactId: 663caecf-31b0-4968-b3af-198e8b3f06ea
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 415549 ms
Total Talk Time (AGENT): 203822 ms
Total Talk Time (CUSTOMER): 223175 ms
Interruptions: 5
Overall Sentiment: AGENT=0.7, CUSTOMER=-0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/10/663caecf-31b0-4968-b3af-198e8b3f06ea_20250610T18:27_UTC.wav
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[AGENT][POSITIVE] Thank you for calling American Public Life. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Uh, yes, hi, [PII]. My name is [PII], and I'm actually the subscriber to American Public Life. Um, I recently had an MRI of the breast, which was deemed necessary by the radiologist that had looked at my mammogram prior.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] Um, so they did the um MRI with and without contrast, and I just received the bill from radiology stating that they had submitted the claims to you, but you all had denied it, and I did receive um the, the letter that you all always send and it stated that that was not a covered benefit. I don't know why.
[AGENT][NEUTRAL] OK, let me take a look at that for you. Uh, could I get your policy number?
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] My policy number is, um, it says 22721.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And I have an outpatient benefit certificate. Do you need that?
[AGENT][NEUTRAL] That, OK. That's the policy number. Yes, ma'am.
[CUSTOMER][NEUTRAL] OK, so it's 0213.
[CUSTOMER][NEUTRAL] 48
[CUSTOMER][NEUTRAL] 41 M as in Mary, L as in Larry, the number 8.
[AGENT][NEUTRAL] OK, thank you for that. If you could verify your date of birth, please.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK, thank you. And it's a good callback number for you, [PII]?
[CUSTOMER][NEUTRAL] Yes, that's my landline.
[AGENT][NEUTRAL] Oh, OK. Thank you. And let's see. OK. And so this is in reference to a claim for an MRI that was denied not due to sickness or injury?
[CUSTOMER][NEGATIVE] It said it was denied 0 paid, and then I just recently, yesterday, got the bill from the radiology group stating that they had submitted it to, um, I guess to the insurance for payment, and they never heard.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Back from anyone, so I don't know what's going on.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me look at the claim. I do see the claim here for [PII], so let me see how we received the bill.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, radiology, I've got it.
[AGENT][NEUTRAL] OK, so the diagnosis that um they submitted on the claim?
[CUSTOMER][NEUTRAL] And it
[AGENT][NEUTRAL] Um, it, it's, it's, it would.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] It's considered a routine diagnosis.
[AGENT][NEUTRAL] Um, so if, if he did the MRI due to concerns, I guess he had done a um maybe did an exam, something didn't look right, and so they wanted to do the MRI is what I'm, I'm guessing.
[CUSTOMER][NEUTRAL] Well, they had done my mammogram.
[CUSTOMER][NEUTRAL] Close to about a year ago. The radiologist came out. Um, my mom and my sister are both breast cancer survivors. I've already had two biopsies, and she said that because of my family history and the dense tissue in my breast that it was essential that I have an MRI done.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] So I submitted it, they submitted it to um United, the request as far as why it was required. United finally ended up paying for it. Um, but then I see, and it just basically states that they have not gotten any feedback or anything back from my supplementary, uh, insurance. So I don't know, but it was, and I'm supposed to have one a year from now on because of my
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so, so the claim.
[CUSTOMER][NEGATIVE] Issue with my breast.
[AGENT][NEUTRAL] Like I said, because of the way it was billed, the way they coded the claim, uh, the codes used are routine, uh, diagnosis codes. Now, if there was, um, you know, they can always submit a uh a corrected claim if there is, uh, you know, if, if, if, if it was miscoded.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Uh, but based on the way it was coded, um, like I said, it's, it does show family history, which is not, you know, if there was personal history, then that would, you know, that would be, uh, a covered benefit, but with it being family history and then let me look at how else.
[CUSTOMER][NEUTRAL] Yeah, I know, because I, I've already had two biopsies. I have calcification.
[AGENT][NEUTRAL] OK. Yeah. And then the first one is just uh a screening, which again is not.
[CUSTOMER][NEUTRAL] So, I mean.
[CUSTOMER][NEGATIVE] Yeah, I know, so it was coded incorrectly fair and is what you're saying, and that's the reason that you all denied it.
[AGENT][NEUTRAL] Uh, considered a cover.
[AGENT][NEUTRAL] If, if it, if it's incorrect, I can't say that it's incorrect, uh, but, you know, that's the codeine that they use. It's just the codeine that they did use. It's not a covered, uh, diagnosis code.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. So I'm gonna give them a call because this is not my understanding, and the reason that the radiologist insisted on me having this done is because of my uh previous history, my potential for the and, and I think, I don't know if they sent you the report from the radiologist, but it said
[CUSTOMER][NEGATIVE] Like I'm highly susceptible to breast cancer.
[AGENT][NEUTRAL] OK. No, they didn't send reports. Um, but again, it's, it wouldn't be based on the reports. It's, it's based on the way they submit[PII] the claim and what they're saying, their reason for doing the MRI.
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEUTRAL] Can I be
[CUSTOMER][NEUTRAL] Yeah I know.
[AGENT][NEUTRAL] Is, is our routine. These are like routine checkups. So your policy only pays for services due to injury or sickness. Routine services would not be covered.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, so I'm gonna give them a call and I'd like for them to review their information because it's um I mean, the report states.
[CUSTOMER][NEUTRAL] That I mean, I have to be followed every 6 months.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] Because of issues, and it says that I'm highly susceptible.
[AGENT][NEUTRAL] OK. Yeah, I would just, you know, give them a call and let, let them know the reason for the denial, that the, you know, based on what we receive, services are, uh, you know, it's showing as a routine service, a routine MRI and your policy does not pay for routine services. And maybe they, at, at that point, they can, you know, take a look at it if they feel that they should resubmit a corrected claim.
[CUSTOMER][NEUTRAL] So, I don't know why they would have not.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK. OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Then, you know, they can definitely do that.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All right. Well, I certainly appreciate it, [PII]. Thank you so much.
[AGENT][POSITIVE] You're welcome. You have a wonderful day. Thank you for calling APL.
[CUSTOMER][POSITIVE] Thanks. You too. You take care. Bye. Bye.
[AGENT][NEUTRAL] You too. Bye bye.