AccountId: 011433970860
ContactId: 6b804359-c4c1-4fe3-a6ee-5fce6f54fafd
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1287349 ms
Total Talk Time (AGENT): 242003 ms
Total Talk Time (CUSTOMER): 286181 ms
Interruptions: 0
Overall Sentiment: AGENT=0.3, CUSTOMER=-0.9
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/13/6b804359-c4c1-4fe3-a6ee-5fce6f54fafd_20250213T16:39_UTC.wav
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[AGENT][NEUTRAL] Good morning. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, good morning. I'm calling about my claim that I submitted.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] Um, on the [PII], um, when I checked online it says nothing was paid out and I wanted to, uh, know what happened.
[AGENT][NEUTRAL] OK, sure, I can assist you with claims. So may I have your name?
[CUSTOMER][NEUTRAL] Uh, [PII].
[AGENT][NEUTRAL] OK. May I have a callback number just in case we get disconnected Miss [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, thank you. And do you have the policy number?
[CUSTOMER][NEUTRAL] Uh, one second.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] 245-505-9
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And may I have your date of birth, mailing address and email address for verification.
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][NEUTRAL] What's the email address?
[CUSTOMER][NEUTRAL] Oh, I'm sorry, um, the [PII].
[AGENT][NEUTRAL] It's OK.
[AGENT][POSITIVE] OK, perfect, thank you.
[AGENT][NEUTRAL] 0
[AGENT][NEUTRAL] OK, it looks like um.
[AGENT][NEGATIVE] There are 2 of them. They are processing 1 today for payment and then there's one that is denied. Let me go ahead and pull the one that is denied and see why.
[CUSTOMER][NEUTRAL] So the one on the [PII], um, I, I submitted one for 250 and 110, so that one is, is in process.
[AGENT][NEUTRAL] I see the one for 110, it looks like that one is about to pay.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, um, there was one for 2:50?
[AGENT][NEUTRAL] Um, the other one.
[AGENT][NEGATIVE] OK, that's, I think that's the one that is denied. Let me see why it denied.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Well, this one is pharmacy, so this is not here.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] What is the date of service for the one that is denied?
[AGENT][NEUTRAL] And the, I'm sorry for the 250.
[CUSTOMER][NEUTRAL] OK, one second.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] yeah.
[CUSTOMER][NEUTRAL] All right. OK, see.
[CUSTOMER][NEUTRAL] The one for 2:15.
[CUSTOMER][NEUTRAL] Um, that one was 113 25, that was for.
[CUSTOMER][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] It was for chemotherapy, um, infusion, so I'm not sure why it was denied.
[AGENT][NEUTRAL] OK. So that one is missing the diagnosis code.
[CUSTOMER][NEUTRAL] Um, it should have been on the, on the claim forms.
[CUSTOMER][NEUTRAL] I downloaded the
[CUSTOMER][NEUTRAL] Um, what you call it, the form from directly from the insurance.
[CUSTOMER][NEUTRAL] Website
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] The diagnostic code.
[CUSTOMER][NEUTRAL] It's, it's everything on here.
[CUSTOMER][NEUTRAL] I don't know.
[AGENT][NEUTRAL] Let me look at the documents really quick.
[CUSTOMER][NEUTRAL] Yeah, it's uh, I mean, that's the one I've been submitted whenever I have to pay out of pocket.
[CUSTOMER][NEUTRAL] It's for my fusion.
[CUSTOMER][NEUTRAL] Um, let's see.
[CUSTOMER][NEUTRAL] I mean, I don't know what
[CUSTOMER][NEUTRAL] Where to find a code, but.
[CUSTOMER][NEUTRAL] It it says on there.
[CUSTOMER][NEUTRAL] Um, injection.
[CUSTOMER][NEUTRAL] Symbolized, whatever, I don't know what that word is.
[CUSTOMER][NEUTRAL] Uh, it says my plan pays 21,000 and my portion is 250.
[CUSTOMER][NEUTRAL] Uh, the note says BD0CP, I don't know what that means.
[AGENT][NEUTRAL] What page are you looking at so I can follow you.
[CUSTOMER][NEUTRAL] Uh, I'm looking on the um.
[CUSTOMER][NEUTRAL] If you scroll down the way it says in the details, it says here's a detailed breakdown of explanation of benefits.
[AGENT][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] And there's like a list of
[CUSTOMER][NEUTRAL] All the different things.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] That one doesn't have a diagnosis code. The diagnosis code is gonna be on the itemized bill. Um, the explanation of benefits doesn't have the diagnosis code.
[CUSTOMER][NEUTRAL] OK, I don't have a bill yet. This is just, this is what I always submit from the insurance.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK, I will reach out to them and see if I can get a bill.
[CUSTOMER][NEUTRAL] Um, and so the one for 110, it has a diagnostic code on there?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mhm, yeah, let me, let me check those documents. One moment.
[AGENT][NEUTRAL] Let me pull that one.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] 6538.
[AGENT][NEUTRAL] OK, the number is 6.
[AGENT][NEUTRAL] I'm waiting on the documents for that one, OK?
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you for your patience.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] OK, it is 20 pages, so I'm just going down the list. OK, one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And this was for physical therapy, correct?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It
[AGENT][NEUTRAL] still I'm looking for that.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] You know.
[AGENT][NEUTRAL] Can I find the diagnosis code.
[CUSTOMER][NEUTRAL] I've, I've always submitted, um.
[CUSTOMER][POSITIVE] The explanation of benefits for all my claims I've never submitted a bill. I've never had any issues before.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Hey, there is, I'm, I'm looking at, I'm trying to find physical therapy and see why they pay that physical therapy, but they did not pay that because um usually when they have another physical therapy, that's what they go by, but I can't see let me see if there's any other claims for that date of service that might have the diagnosis code.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Yeah, I do see a diagnosis here for that.
[AGENT][NEUTRAL] C, the diagnosis code is C50.919.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So, it's on the one for physical therapy, but it's not on the another one?
[AGENT][NEUTRAL] No, it's not. Mhm.
[CUSTOMER][NEUTRAL] Hm.
[AGENT][NEUTRAL] And yeah, this was based off um.
[AGENT][NEUTRAL] Yeah, you have physical therapy in the past, so they just placed that code on that one. But yeah, that one had a two diagnosis codes. C5919, the other one is C50.311.
[CUSTOMER][NEUTRAL] But I
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] But I've had claims for for um.
[CUSTOMER][NEUTRAL] A chemotherapy before, so.
[CUSTOMER][NEUTRAL] It's the same one that I did for the 250. I've had claims for um for that before. Most of my claims last year was related to that, um.
[CUSTOMER][NEUTRAL] Let me see, but if you look at most of my claims for last year, they're all related to a chemotherapy.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] And I got, I got paid for those and I didn't download a bill. I, I, I uploaded the benefits, the explanation of benefits.
[AGENT][NEUTRAL] I'm sorry.
[AGENT][NEUTRAL] OK, at this point, the only thing I can do is uh request for an examiner to review and give you a call back um because um.
[AGENT][NEUTRAL] They're the ones that process the claim and I only have the information of what's needing or what's needed or what's missing. um.
[AGENT][NEUTRAL] But I don't have anything else. Is it OK if they call you back within 24 hours?
[CUSTOMER][NEUTRAL] Yeah, that's fine. Um, do you, you guys don't pay for, um, pharmacy claims?
[AGENT][NEUTRAL] We do not cover pharmacy. Mm mm.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] OK, so, um, so you're saying that you, you said the 110 will be paid, but someone will call me about the other claim?
[AGENT][NEUTRAL] Correct. I'm gonna go ahead and send a uh request for review on this one and ask the uh the examiner to call you.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, and if you can just let them know, if you can let them know in the notes to send my to look at my claims from last year, uh, 90% of them were related to the same treatment that I, I just submitted a claim for, which is my chemotherapy infusion.
[AGENT][NEUTRAL] With any updates.
[AGENT][NEUTRAL] Do you mind holding for me just a minute? I'm just gonna go ahead and check, um, I'm just gonna send a message over and see if they can respond on that really quick. If not, then we'll go ahead and wait for that call. OK, one moment. You're welcome.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] OK, thanks.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Thank you for holding and being patient for me.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, um, Ms. [PII], um, she said that she will have to review again the documents and make sure she didn't miss that diagnosis code, but, um, she's gonna give you a call back.
[CUSTOMER][POSITIVE] OK, that's fine. Thank you.
[AGENT][POSITIVE] You're welcome and thank you for calling ATL. Have a good day.
[CUSTOMER][NEUTRAL] You too.
[AGENT][POSITIVE] Thank you. Bye-bye.