AccountId: 011433970860
ContactId: 74189952-9f21-4d4d-abdc-c8e8f6be5503
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 637260 ms
Total Talk Time (AGENT): 236342 ms
Total Talk Time (CUSTOMER): 281202 ms
Interruptions: 1
Overall Sentiment: AGENT=0.7, CUSTOMER=0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/19/74189952-9f21-4d4d-abdc-c8e8f6be5503_20250219T21:14_UTC.wav
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[AGENT][POSITIVE] Thank you for calling APL this is [PII] how may I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. Good afternoon. Um, I'm calling because I, uh, submitted a claim and I just received the results and it was basically stating that what I submitted wasn't covered by the policy and to please provide a diagnosis code which I had in the um
[CUSTOMER][NEUTRAL] Title of the PDF that I had uploaded, um.
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So yeah, I'm just trying to get some more information as to how to go about and I guess appeal it.
[AGENT][NEUTRAL] OK, I can help you with that. Uh, can you please give me your name and your policy number?
[CUSTOMER][NEUTRAL] Of course, my name is [PII]. The policy number is 2,326,720.
[AGENT][POSITIVE] OK, thank you Miss [PII], and I can help you with your claim. Let me pull up this policy real quick.
[AGENT][NEUTRAL] OK, Ms. [PII], can you please verify your date of birth for me?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you ma'am and then also I'll need for you to, for security reasons, verify your address, a phone number and email address that we have on the policy for you.
[CUSTOMER][NEUTRAL] No problem. It's [PII]. Phone number [PII]. Email [PII].
[AGENT][NEUTRAL] OK, it looks like I have a work email address for you.
[CUSTOMER][NEUTRAL] Oh, I updated that recently. Um, it might be [PII], but that should have been updated last time I called on the [PII], I think.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, um, can you give me the email address you'd like for it to be again and I can change it for you?
[CUSTOMER][NEUTRAL] Of course. It's [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me go in and get that updated real quick.
[CUSTOMER][POSITIVE] It's funny cause I, when I set up my online service, I received an email at that email address saying thank you for activating your online service account.
[CUSTOMER][NEUTRAL] So, I don't know is it disconnected.
[AGENT][NEUTRAL] Oh my.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] I just noticed when you verified that it wasn't the same email address that you had used to to verify that's why why I wanted to ask you.
[AGENT][NEUTRAL] What it was just in case you wanted to change it.
[CUSTOMER][POSITIVE] Yeah, that's, I mean, I appreciate it.
[AGENT][POSITIVE] No problem at all.
[CUSTOMER][NEUTRAL] I do, yeah. I mean, like I said, I thought I did and I don't know why it didn't capture or what.
[AGENT][NEUTRAL] OK, I've got it updated. It's, it's the correct email and I made sure that it's stuck. um OK, let me go back to the claims for you. I see that there's just one claim, uh, let me look at the remarks on the claim.
[AGENT][NEUTRAL] OK. So, um, the office visit that was filed on the claim is not covered by the policy. And then for the rest,
[CUSTOMER][NEUTRAL] Right. I added
[CUSTOMER][NEUTRAL] Go ahead.
[AGENT][NEUTRAL] And then for the rest of the claim um I know you stated that you added the diagnosis code on the PDF, but what we need is an itemized statement from the provider that has your diagnosis and procedure codes and you could submit those and then they'll uh reexamine the claim.
[CUSTOMER][NEUTRAL] So, let, can I, let me grab my explanation of benefits. Just give me a moment, please.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Hi.
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] Um, so when I uploaded the documents, the explanation of benefits, I understand the office visit isn't covered, which is fine, um, but I was looking to have the medical equipment covered, um, which is why I attached my visit on [PII] to it.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Um, so, I'm looking at my explanation of benefits and
[CUSTOMER][NEUTRAL] Doesn't really break it down the way you guys want, of course. Um, but I think when I was looking online at my policy, there was
[CUSTOMER][NEUTRAL] Like the claim details, I think is what it was, and it has uh
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It says date, service dates, and then type of service. But I, I know that it doesn't list anywhere in the diagnostic code because I have to reach out um to the insurance to find out what it was, uh, which is
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] What I wrote on, like I said, the title of the PDF um G47.33, so where would I get that, um, I guess in a formal document like who do I get that from?
[AGENT][NEUTRAL] You get it from the provider, the, the provider of your services, and it's called an itemized statement and it'll have your diagnosis and procedure codes on it.
[CUSTOMER][NEUTRAL] I'm sorry, tell me again. It's called what?
[AGENT][NEUTRAL] It's called an itemized statement.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And when you say the provider, do you mean the doctor or the company that's providing me with the equipment?
[AGENT][NEUTRAL] Uh, the provider that you went to that you went to that um wants you to have the.
[CUSTOMER][NEUTRAL] Of course of course.
[AGENT][NEUTRAL] Equipment, yes.
[CUSTOMER][NEUTRAL] OK, so call them, ask them for an itemized statement that lists.
[CUSTOMER][NEUTRAL] You said a couple of things. Do you mind repeating that?
[AGENT][POSITIVE] No, I don't mind at all. And it looks like it's Lincare if that helps you any Lincare.
[CUSTOMER][NEUTRAL] Well, Lin Lincare is the provider that provided the equipment. However, Doctor [PII] is the one that requested the equipment for me.
[CUSTOMER][NEUTRAL] So,
[AGENT][NEUTRAL] OK, yes.
[AGENT][NEUTRAL] So the doctor would be the one who would give you the diagnosis for why you need the equipment. So we need the itemized statement.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] That has the diagnosis and procedure codes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] And I'm assuming it needs to have my name on it and all of that fun stuff.
[AGENT][NEUTRAL] Yes. And when you tell them you need an itemized statement with uh diagnosis and procedure codes, a detailed, you can tell them you want it detailed, um, they'll know what you mean.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] I hope so. I haven't really had the best experience with their office.
[AGENT][NEGATIVE] Oh, no.
[AGENT][NEUTRAL] But yes, once you send that in, um, you'll have all three components of your claim, which is the EOB, the claim form, and the itemized statement, and they'll reprocess the claim.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. And then, so when I do have that, it said on one of the things that I could um do an appeal?
[AGENT][NEUTRAL] Yes, um,
[CUSTOMER][NEUTRAL] Is that something I do online as well?
[AGENT][NEUTRAL] Right and appeal what that means is if you're after your claim is reprocessed after you send in the information that they're requesting now and if they um.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Find for any reason that they're going to deny the claim they'll send you a notice and let you know it's denied at that time, um, you can appeal it. You have 180 days from the date that the claim was submitted.
[AGENT][NEUTRAL] And you'll need to send a letter as to why you need to appeal, but right now is basically just asking for that extra piece of information so that they can finish processing the claim.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK. I will contact their office and hopefully, they're able to help me out.
[AGENT][POSITIVE] Yes, ma'am. I hope so too. I hope they give it to you right away.
[CUSTOMER][POSITIVE] Me too. Thank you for your help, Sorry. Have a great day.
[AGENT][POSITIVE] You're very welcome, Ms. [PII]. You have a blessed day too, and thanks for calling APL.
[CUSTOMER][POSITIVE] Thank you. Bye-bye.
[AGENT][NEUTRAL] Oh.