AccountId: 011433970860
ContactId: 70123349-8477-428d-bfa1-8e498c5ac093
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 448359 ms
Total Talk Time (AGENT): 147210 ms
Total Talk Time (CUSTOMER): 235134 ms
Interruptions: 1
Overall Sentiment: AGENT=1, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/28/70123349-8477-428d-bfa1-8e498c5ac093_20250328T12:30_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Uh yes ma'am my name is [PII]. I filed a claim, um, on the website or submitted a claim and it was, I come back, um, unapproved, um, and I was just trying to clarify before I call the provider or take any further action, um, what exactly I'll need to correct to get the claim approved.
[AGENT][NEUTRAL] Uh, did you receive a text notification?
[CUSTOMER][NEUTRAL] I did, yes, ma'am.
[AGENT][NEUTRAL] OK, and did it, what it, what information did the techs give you just the pol the claim number maybe?
[CUSTOMER][NEGATIVE] It did, but then I went to the portal and I pulled up the claim and I opened up and I've read the document that gives the reason, but I want clarification on that particular reason because I, it says I need to submit, it says I need to submit codes and I submitted an EOB and a download from the Novo app. I did not submit the item it was itemized, but it wasn't a formal invoice and I don't know if that's the issue or if the codes are not the correct format codes that you guys are looking for.
[AGENT][NEUTRAL] Got it.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Understood. What's your policy number?
[CUSTOMER][NEUTRAL] Oh, policy number, does that.
[AGENT][NEUTRAL] Or you can give me the claim number.
[CUSTOMER][NEUTRAL] Oh, claim number is 3,581,780.
[AGENT][NEUTRAL] Mhm, can, uh, uh, provide a good call back number in case we're disconnected.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Give me one moment to pull up your information.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] [PII], verify your date of birth, your mailing address, and a good, um, your, your date of birth and your address.
[CUSTOMER][NEUTRAL] [PII] and I'm at [PII].
[AGENT][NEUTRAL] And what state is that?
[CUSTOMER][NEUTRAL] I'm sorry, [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Alright, so in order to consider further consideration of this loss or claim under this policy, we will need supporting documentation.
[AGENT][NEUTRAL] Is that what your explanation reads?
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] To evidence the accident or sickness?
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] But so I, I, what does that entail? What documentation? Because I provided the explanation of benefits and I also provided a screenshot from, like I said, from their app which has the line items and the testing and everything that they did.
[CUSTOMER][NEUTRAL] Um, and it has uh what looks appears to me to be the code, the proper insurance code 9921387651, but my, I recall previous instances where I submitted a claim and, and whatever the format wasn't right, so I had to call the vendor and say, you know, get the proper insurance code. So I don't know if that's the issue or if you're.
[CUSTOMER][NEUTRAL] If it, I, I do note that it mentioned something about a test result, I, do I need to call and get some sort of formal letter or correspondence from the vendor stating that yes, I was diagnosed positive with COVID. But they tested me for strep, they tested me for flu, and they tested me for COVID. I was positive for COVID. So is that what you need, a positive result for the COVID? Like you only pay it out if, if, if I deposit?
[AGENT][NEUTRAL] So are
[AGENT][NEUTRAL] So I heard you say that the procedure codes are on the document. What about the diagnosis codes?
[CUSTOMER][NEUTRAL] That that's my, that's what I was trying to confirm if that's what you're missing because I don't, I don't, I'm not a medical professional. I don't know the difference, and I don't recall. So I'm assuming the 99213, the 87651, those are not the codes you need. You need a what's called a diagnostic code, is that correct?
[AGENT][NEUTRAL] So we do need, we do need the codes that you specified in addition as that explanation reads it says procedure codes and.
[AGENT][NEUTRAL] Diagnosis codes. So the diagnosis would be, you know, what did they diagnose you with? Let me look at the document that you uploaded real quick, OK?
[CUSTOMER][NEUTRAL] Yeah, it's not, I, I'm looking at the, like I had mentioned, it, it didn't have it, it was an itemized statement from their, from the, the Go Health portal, the Nova portal where it's all on, it's an app. Um, so I, I hadn't, I had trouble tracking down a formal bill, um, but I thought that was sufficient since I had the same codes that had the same line items as the estimation of benefits, and I had the vendor name at the top.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][MIXED] Um, I now have the itemized bill, the proper bill, but it doesn't have even those those insurance codes on it. So I would need, if I need diagnostics codes or something else, I would need a different document from Nova, and that's a pain in the ass, obviously, but that's fine. Um, but if that's what I need, that's fine. I'll, I'll make that, I'll make that move.
[CUSTOMER][NEGATIVE] Ideally, when you give them your card, they would actually follow through with filing your secondary insurance, but they never do.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Correct, so in, in addition to the explanation of benefits that you uploaded, we do need the itemized bill. I'm gonna give you the form name to request when you call the billing department at Novot.
[CUSTOMER][NEUTRAL] Yes, [PII]'am.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Can I get it.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] I'll write it on the chalkboard. OK. No, I was just getting a pen and paper.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Are you a teacher?
[CUSTOMER][NEUTRAL] No, I, I have a, a kid and he has a little chalkboard here in the dining room and I was like, I was rather than running to another room and rifling through a drawer, I had, I was like, I'll just write it on the chalkboard.
[AGENT][NEUTRAL] Oh OK.
[AGENT][POSITIVE] That's cute.
[AGENT][POSITIVE] Comes in handy.
[CUSTOMER][NEUTRAL] He's gonna be, he's gonna be, he's gonna come home and read, he's gonna come home and read it like, Daddy, what is this?
[AGENT][NEUTRAL] What
[AGENT][POSITIVE] I love it. So, um, I'm gonna get.
[CUSTOMER][NEUTRAL] Is because I sometimes put messages on it for him. Anyway, sorry.
[AGENT][POSITIVE] That's, that's cute. I like that. How is your son?
[CUSTOMER][NEUTRAL] He's, uh, he's turned [PII] in July.
[AGENT][NEUTRAL] OK, I like that. So, um, this is the form name that you're gonna request. Um, you wanna ask for the CMS, that's [PII].
[AGENT][NEUTRAL] And then number 1500, so ask for the CMS 1500 form because was that done in a, in like in a doctor's office setting?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Or did you go to the hospital?
[CUSTOMER][NEUTRAL] Yes, I was a, it was a, it was an urgent care, the doctor's office, I guess.
[AGENT][NEUTRAL] OK, so request, ask them for the CMS 1500, that's an itemized bill and any time you submit a claim, that's the form that we need plus the Aetna EOB that you sent us because that'll list all of the codes, the procedure codes which I do see on the EOB, but the EOB is not gonna tell us the diagnosis because it's PHI.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Got you.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So request that form and then you can just upload the itemized bill or the CMS 1500 form, same thing on portal and then we can go back in and review your claim.
[CUSTOMER][NEUTRAL] OK dokes. Um, what?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. OK.
[CUSTOMER][POSITIVE] OK, I appreciate it.
[AGENT][NEUTRAL] All [PII]. Any other questions, [PII]?
[CUSTOMER][NEUTRAL] No, ma'am.
[AGENT][POSITIVE] Alright, thank you for calling APL have a good day.
[CUSTOMER][NEUTRAL] OK.