AccountId: 011433970860
ContactId: 732ac436-15cd-4f8e-9a88-ead959679575
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 728840 ms
Total Talk Time (AGENT): 299978 ms
Total Talk Time (CUSTOMER): 245489 ms
Interruptions: 3
Overall Sentiment: AGENT=0.5, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/14/732ac436-15cd-4f8e-9a88-ead959679575_20250414T18:33_UTC.wav
--------------------------------------------
[AGENT][POSITIVE] Thank you for contacting ATL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hey [PII], I'm calling about some claims that I put through last week um that had said that they were processed and.
[CUSTOMER][NEGATIVE] I don't know if it the text said they were completed but said that they're processed and I'm in the system right now saying that they're processed but there's no payment on them.
[AGENT][NEUTRAL] OK, I can certainly look those up. And what is your policy number, please?
[CUSTOMER][NEUTRAL] Uh, policy number is 025.
[CUSTOMER][NEUTRAL] 644-53
[AGENT][NEUTRAL] Thank you. And if I could just verify your name, uh date of birth, and a phone number, please.
[CUSTOMER][NEUTRAL] [PII] [PII] and my cell number is [PII].
[AGENT][POSITIVE] OK, I do appreciate that. Thank you. So this is Northwest Georgia Medical. Does that sound right?
[CUSTOMER][NEUTRAL] Uh, yeah, there were 2.
[CUSTOMER][NEUTRAL] I guess it's two different claims, but um.
[CUSTOMER][NEUTRAL] I had sent through and scanned my information with the the detailed billing because they wanted detailed billing which I got from the hospital and then one of the claims was Northeast Georgia and Doctor [PII] together.
[AGENT][NEUTRAL] Doctor, OK, yes, I see that.
[AGENT][NEUTRAL] Yeah, let's see what we have here.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So, what, uh, we do have them, uh, we do have all of your um documentation. Now, the one thing that we need is uh
[AGENT][NEUTRAL] The diagnosis code, um,
[AGENT][NEUTRAL] They have changed the way that we can accept the diagnosis code. We used to have, uh, you could use to just write it in or tell us what the symptoms were, and we would look up the documentation. What they're looking for now is, um, is the assessment or the diagnosis code from the provider. And so we know, we can only accept the diagnosis code if it's come from the provider themselves. And usually what this is listed as on your bill is the assessment. Now, we looked for that.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, it's the, you know, because whenever you're in the, the doctor's office or the hospital, uh, they come up with the diagnosis code and they put it in their notes and things like that, but they will give that to you. Uh, it usually, um, uh, see, there's several things that are, that they will have that information on. Let me just check here.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] So,
[CUSTOMER][NEUTRAL] Yeah, because um they told me that they needed the specific billing with the codes and all that, so I contacted the hospital and Doctor [PII] and they both gave me um.
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] You know, I had to wait for the detailed billing to come in the mail and Doctor [PII] says pretty specific that's detailed billing and then the hospital.
[CUSTOMER][NEUTRAL] was just, you know, whatever, you know, they knew what I was talking about as far as the details with the diagnostic codes on it. Um, does that billing not have the right codes?
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] That's, that's what I'm looking for right now, um, because usually they'll, they'll have it on the, sometimes they'll have it on the diagnostic testing results. Sometimes it's on the, uh, on the, um, facility bill, um, discharge, uh, you know, where they, um, so that's what I'm looking for right now and it does, let's see what we have here.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, that's it.
[AGENT][NEUTRAL] OK, sure uh.
[AGENT][NEUTRAL] So the, let's see, um, what I'm doing right now is I'm just going through the bill. Now they, um, the CPT code is, is a little different from the, from the diagnosis code. So the CPT code lets us know what they did. The diagnosis code says why, and that's what I'm looking for right now. So I'm going through the, the uh itemized billing that you got from [PII], what is this? and [PII] [PII], so that's what I'm going through right now.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right, OK, OK.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] OK, so I don't see that on.
[CUSTOMER][NEUTRAL] Because I had them send.
[CUSTOMER][NEUTRAL] Hm.
[AGENT][NEUTRAL] Oh, you had them send all this stuff. Yes, I see that.
[CUSTOMER][NEUTRAL] Yeah, I had them send it all from [PII] and [PII] because all of my medical stuff started happening at the end of November so I was lucky to have to pay my deductible uh twice.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] Let me check here.
[AGENT][NEUTRAL] OK. Let me, um,
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] If, uh, if you don't mind, I'm going to have the um examiner look at this again and, and, uh, we'll see, sometimes we can actually contact the, the provider if it comes to that. So let, let me just see, excuse me just one moment please. I'll be right back.
[CUSTOMER][POSITIVE] That'd be awesome.
[AGENT][NEUTRAL] Yeah, excuse me, just one moment.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, so I'm sending this back to the examiner to have this uh looked at and then we'll see if we can't contact them. If not, um, then we will let you know, um, to see if we can get the, the, uh, diagnosis code. Now, um, since you are online, uh, well, um,
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Either see that it's been updated online or you'll get an explanation of benefits. But I am sending this back to see if we can't uh review this and see if it can't, if we can't find the uh diagnosis code on it.
[CUSTOMER][NEUTRAL] OK. And then, um, in the meantime, if I go to any of those particular doctors, or should I contact the doctor and, and see if I can get a letter from them or something?
[AGENT][NEUTRAL] Uh, you can, um, but let's see if we can't find it here first. If we normally if, if we, uh, let's see if we can't call them and find out and then if not, then we'll let you know. Now we're actually, we actually don't have it, then we will certainly, um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, let you know and then and then you would be able to contact them.
[AGENT][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Yeah, I mean they knew exactly what I was talking about about the detailed billing with the codes and so I'm surprised that they.
[CUSTOMER][NEUTRAL] You know, when I waited for them and then I attached them to my claim, so I'm surprised they would send something that I didn't need.
[AGENT][NEUTRAL] Oh, well, sometimes, I mean, there's a lot of things on there. Um, these things are really, as you've noticed, I'm sure from looking at them, there's just a lot going on with these uh with these things, so, and so, um,
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, right, sure.
[AGENT][NEUTRAL] Uh, we can, um, let's see, this is what.
[AGENT][NEUTRAL] What thing is this from?
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] What have we got here? Because it looks like what 11:20, 11:28.
[AGENT][NEUTRAL] Um, uh, I see that's when you, it went to your, uh,
[AGENT][NEUTRAL] Through Aetna. So, yeah, sometimes it just take there's a lot of things on here, sometimes it takes a lot of time to get it through, um, but, um, let's, yeah, let's see if we can't do it and then if not, then, then, um, you would need to contact them uh yourself and see because sometimes they just won't give it to us.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, but well, let's see if we can't call Northeast.
[CUSTOMER][NEUTRAL] Mhm. Well, and so somebody, somebody will, yeah, somebody will let me know though either way, right?
[AGENT][POSITIVE] Yes, absolutely we'll let you know, um, certainly we'll let you know so if you don't mind looking at the, at the, you'll probably see it um before I get a chance to call you back.
[CUSTOMER][NEUTRAL] OK, OK.
[AGENT][NEUTRAL] You'll probably see it tomorrow.
[CUSTOMER][NEUTRAL] OK, just keep.
[CUSTOMER][POSITIVE] Alright, alright, awesome OK I'll just keep watching.
[AGENT][NEUTRAL] We will certainly let you know. OK, now is there any, any other claims that we need to look at or anything else at all?
[CUSTOMER][POSITIVE] All right, thanks so much.
[CUSTOMER][NEUTRAL] No, no, I'm just hoping I can get it done because everybody of course wants their money and.
[AGENT][NEUTRAL] Of course.
[CUSTOMER][NEUTRAL] What ended up happening with me is that for the for for 2024 uh services, I had some skin surgery that was um scheduled and they told me that my deductible at the time was not paid. Um, so I had a doctor collect the $2500 deductible.
[AGENT][NEUTRAL] Right.
[CUSTOMER][POSITIVE] Um, only then to not submit my bills till late in January after all my other bills came in, and so I had already paid them $2500 on my credit card and then so then my insurance said, well, you know, they are gonna get paid 100% for from us.
[AGENT][NEUTRAL] Oh,
[CUSTOMER][NEGATIVE] So I had to wait till the insurance paid them off before they would refund my money because now I have to give that deductible to other doctors that are billing for it so it's just been kind of a mess and so I'm hoping to get some money so I can start paying these people.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] Yes, of course, absolutely. Well, we'll, we will have this reviewed and see if we can't do it and if it's, if it does end up being that we, that, uh, [PII] has to be contacted again, we can try it and then if it doesn't work with us, then we'll ask you to do it.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Yeah, that'd be great. I appreciate it.
[AGENT][POSITIVE] OK. Well, thank you very.
[CUSTOMER][POSITIVE] OK, I'll just keep watching my file. Thanks so much.
[AGENT][POSITIVE] Yes please, thanks for contacting AP have a good day.