AccountId: 011433970860
ContactId: 79c5bb04-3e83-48c9-b10e-cc11544b368f
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 978539 ms
Total Talk Time (AGENT): 448174 ms
Total Talk Time (CUSTOMER): 291929 ms
Interruptions: 0
Overall Sentiment: AGENT=0.9, CUSTOMER=1.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2024/12/30/79c5bb04-3e83-48c9-b10e-cc11544b368f_20241230T13:49_UTC.wav
--------------------------------------------
[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey [PII], my name is [PII]. I'm a broker. I'm just trying to trying to check on two claims for one of our customers.
[AGENT][NEUTRAL] OK, [PII], you're needing to check on 2 claims for 1 member, is that correct?
[CUSTOMER][NEUTRAL] It it's actually uh one claim for two different members.
[AGENT][NEUTRAL] OK. Yes, I can help you with that, [PII]. And what is your callback number, please?
[CUSTOMER][NEUTRAL] It is [PII].
[AGENT][NEUTRAL] Thank you. And what is the first member's policy number?
[CUSTOMER][NEUTRAL] First policy number is 2446222.
[AGENT][NEUTRAL] OK, thank you, one moment.
[AGENT][NEUTRAL] And any information, [PII], that I do provide for you today will be a verification of benefits and not a guarantee of payment. And as you know, I do have to verify a few things with you first for security. So first off, if you could please verify the patient's name and date of birth.
[CUSTOMER][NEUTRAL] This is Miss [PII] and it's [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And then your email address, please?
[CUSTOMER][NEUTRAL] My email address is [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] OK, thank you very much.
[AGENT][NEUTRAL] And then [PII], what is the date of service and total bill amount that you're calling about?
[CUSTOMER][NEUTRAL] Um, for I know these were sent in on [PII] and [PII] trying to see if it shows data service on here.
[CUSTOMER][NEUTRAL] Let's see if it shows it here. I think date of service was [PII] apparently she was bit by a bee or something.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Uh, insect, I believe.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] OK, so I do have two separate claims uh for that data service that I do show that you are submitted. Those have both been denied, [PII], let me look at the reason.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK just one moment.
[AGENT][NEUTRAL] OK, so the code on each of these is the same as far as the denial, and I'll just read this to you. Receipt of the claim is acknowledged. However, in order to provide further consideration of this loss under this policy, we will need supporting documentation to evidence the accident.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] And when it occurred. Supporting excuse me, supporting documentation may include, but is not limited to office notes, hospital admission and discharge summaries, and or diagnostic testing results.
[CUSTOMER][NEUTRAL] OK, let me see here.
[CUSTOMER][NEUTRAL] I was looking at I was just pulling up what we sent in. I see the claim form and then I see where it says North Oaks physician Group, and then it talks about.
[CUSTOMER][NEUTRAL] Encounter diagnosis.
[CUSTOMER][NEUTRAL] Second thing down says insect bite initial encounter.
[CUSTOMER][NEUTRAL] I'm just scrolling down real quick just to see what they would have looked at and not like on here.
[AGENT][POSITIVE] Sure. Oh yeah, you can.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, because I'm normally pretty good at these and I tell people if it looks good send it and um I'm looking to scrolling down even further here's the after visit summary.
[CUSTOMER][NEUTRAL] Um, insect bite of [PII].
[AGENT][POSITIVE] Oh goodness.
[CUSTOMER][NEUTRAL] And then I'm gonna
[CUSTOMER][NEUTRAL] Trying to see what was kinda.
[AGENT][NEUTRAL] So what I can do, [PII], is I can, I can go ahead and check the other member if you want, and then I can connect you over to one of the examiners who reviews this type of claim, and they can take a look at that to see exactly what we would would need versus what was actually sent in. Mhm.
[CUSTOMER][NEUTRAL] Not to their liking on this one.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Sure, and and on the second attachments, it's actually UBO4s which normally work best for us and, uh, one of the first two codes is bite insect bite.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so yes, once I, um, if you want me to, I'll go ahead and look up the other one and then.
[AGENT][POSITIVE] I can get you connected over so they can take a look at those with you.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so what's the next policy number that you have?
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] OK, I'm sorry, you're talking about for the second person? OK, I'm sorry, let me do this.
[AGENT][NEUTRAL] Uh-huh, yeah.
[CUSTOMER][NEUTRAL] Let me go check here.
[AGENT][NEUTRAL] And then we'll just come back to this one.
[CUSTOMER][NEUTRAL] Sure, sure, it's uh.
[CUSTOMER][POSITIVE] I have it right here.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So be for [PII] is on his daughter, [PII].
[CUSTOMER][NEUTRAL] Policy number.
[CUSTOMER][POSITIVE] And this is funny, not funny, but my son Drew all over it this morning as I was waiting to call in, so it's, uh, he thinks it's funny when he writes all over my notes, you know.
[AGENT][NEUTRAL] Oh,
[AGENT][POSITIVE] Oh bless him. How old is he?
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] He's [PII].
[AGENT][NEUTRAL] Ah, oh yeah. Oh yeah.
[CUSTOMER][NEUTRAL] So he wants to show me how good he draws, but he draws right over my handwritten notes on here.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][POSITIVE] Oh, that's so cute.
[CUSTOMER][NEUTRAL] Alright, let's see. Oh, thank you, um, OK, so it looks like it's a claim under the accident in the hospital, um, but the, the main one I think is that it fell under was the accident, and it's uh 241-9234.
[AGENT][NEUTRAL] OK, thank you. One moment.
[CUSTOMER][NEUTRAL] And then whenever I get on a work call, he tries to he talks extra loud, uh, just so I can, you know, yeah.
[AGENT][NEUTRAL] Of course.
[AGENT][NEUTRAL] Of course they do.
[AGENT][POSITIVE] Little children have a thick fence for sure.
[CUSTOMER][POSITIVE] That's right, that's right.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and on this policy, what is [PII]'s date of birth?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] [PII]'s date of birth is [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and the date of service on this one?
[CUSTOMER][NEUTRAL] I believe it's [PII].
[AGENT][NEUTRAL] OK, and
[AGENT][NEUTRAL] Do you have a total bill amount on this one, [PII]?
[CUSTOMER][NEUTRAL] I don't, I can give you.
[CUSTOMER][NEUTRAL] Other information um.
[CUSTOMER][NEUTRAL] That that may help you.
[CUSTOMER][NEUTRAL] I never really know what they mean by total bill amount is this like the, like how much is on the bill itself?
[AGENT][NEUTRAL] That's
[AGENT][NEUTRAL] That's was totally billed, yes, to their insurance or, yeah, on the itemized bill, the total bill amount.
[CUSTOMER][NEUTRAL] Let's see.
[AGENT][NEUTRAL] We only have one claim that you all submitted, so give me just a moment.
[CUSTOMER][NEGATIVE] I got an itemized bills.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I see $1,813 and $3,929.
[AGENT][NEUTRAL] OK. So on here.
[AGENT][NEUTRAL] I can see that on the [PII] we processed this claim.
[AGENT][NEUTRAL] Um, there was a benefit that's been issued to them in the amount of $1,725.
[AGENT][NEGATIVE] There was one code on here that was denied.
[AGENT][NEUTRAL] And that was for the 99283, that the charge on that was 181384.
[AGENT][NEUTRAL] And it states.
[AGENT][NEUTRAL] We will pay the emergency room treatment benefit amount shown in the schedule of benefits for each day a covered person receives treatment in an emergency room as a result of a covered accident. This benefit is payable once per covered accident and is payable up to the number of days per plan you each covered person as defined in the policy certificate. This benefit is only payable once per day. If treatment in emergency room, chiropractic office, physical therapist office.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Physician's office and or urgent care facility as applicable under the certificate occur on the same day, only the highest benefit is payable. This payment represents the maximum payable amount under this benefit for this data service. So we have paid on one of the other codes on that claim.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Basically saying that they won't pay for 2 visits in one day, is that what they're saying?
[AGENT][NEUTRAL] Correct. They will, we will pay the higher of the two.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] They could probably shorten that, uh, because it probably confuses people. They're like, wait, what it's uh.
[AGENT][NEUTRAL] Yeah, I know it has, you know, all the legal stuff, but yes, there was another code and that's for.
[AGENT][NEUTRAL] According to what I can see, there was another one for a charge of $287268 so we paid $300 on that.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, OK, that's perfectly fine, um, OK, so for the accident itself they paid $1,725.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Do you show a separate benefit under the hospital plan?
[AGENT][NEUTRAL] I'll have to pull that policy up.
[AGENT][NEUTRAL] Um
[CUSTOMER][NEUTRAL] I'm sorry.
[AGENT][NEUTRAL] OK, now, I see there were two claims, yeah, those two claims have not been reviewed yet. I see there was an upload on the [PII] and the [PII].
[AGENT][NEUTRAL] Under you all
[CUSTOMER][NEUTRAL] Oh no you're right, sorry, my screen says received and did not processed, OK.
[AGENT][NEUTRAL] But it hasn't
[AGENT][NEUTRAL] Yeah, but it has not been reviewed yet, so there it's in line.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Got it, got it. So on the hospital plan, just by glancing at it, I can tell they paid the $300 the $300 for the X-ray that's 600, and I have to assume yes ma'am, I'm sorry, and uh, so I have to imagine that the leftover.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] On the accident.
[AGENT][NEUTRAL] So, yes, uh-huh.
[CUSTOMER][NEUTRAL] 1, 1100 is probably for the fracture and the, I'm sure a follow-up visit or something um.
[CUSTOMER][POSITIVE] And that that's really that's all they're gonna ask me so that's perfectly fine if they ask me anything else I'll circle back to you and I, uh, I appreciate all your time this morning.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Well, you're welcome. Now, did you want me to connect you over on that first, um, [PII]'s policy to have them look at that with you? OK. Well, I'll be happy to do that, [PII]. Is there anything else I can help you with first?
[CUSTOMER][POSITIVE] Sure that'd be wonderful.
[CUSTOMER][POSITIVE] That's it. I hope you have a great day. Happy [PII].
[AGENT][POSITIVE] Well I, I hope you and your family have a happy [PII] as well and thank you again for calling APL. So give me just a second and I'll get you transferred.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] Uh, you're welcome. Bye-bye.
[CUSTOMER][POSITIVE] Thanks, bye-bye.
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][POSITIVE] Thank you for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hi, [PII]. This is [PII]. How are you this morning?
[CUSTOMER][POSITIVE] I'm good how are you?
[AGENT][NEUTRAL] I'm doing fine, thank you. So I have a broker on the line, uh, [PII], and he wants to, uh, go over two claims for a member, please.
[CUSTOMER][NEUTRAL] Uh, let's see.
[CUSTOMER][NEUTRAL] OK, what is the policy number?
[AGENT][NEUTRAL] Alrighty, it is 244.
[AGENT][NEUTRAL] 6222 for part one, Miss [PII].
[CUSTOMER][NEUTRAL] Uh, let's see here.
[AGENT][NEUTRAL] You sound a little under the weather, [PII].
[CUSTOMER][NEUTRAL] Uh, yeah, I was, I have COVID.
[AGENT][POSITIVE] Bless your heart.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEGATIVE] There's a lot of sick people around right now.
[CUSTOMER][NEUTRAL] Yeah, my daughter has COVID and flu.
[AGENT][POSITIVE] Oh. Well, I'll certainly be praying for y'all. I'm so sorry to hear that.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Thank you. So the top two claims?
[AGENT][NEUTRAL] Um, yes, uh 354-525-4 and 3544815. They were denied for the same reason.
[AGENT][NEUTRAL] But he thought that he sent everything that we would have needed and, you know, he just wants to double check what we're missing that wasn't included.
[AGENT][POSITIVE] Nice guy.
[AGENT][NEUTRAL] And she's
[CUSTOMER][NEUTRAL] 8258.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] OK, sorry, I was just reading the uh.
[AGENT][NEUTRAL] No, yeah, you're fine.
[CUSTOMER][NEUTRAL] OK, yeah, you can send them through. I'll have to take a look. I don't, that's a lot. That's a broad band of documentation that's needed.
[AGENT][NEUTRAL] Because he
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right, but he said that he included the UBO4 and um something else. I checked a couple of claims for him, but this was the only one, and this was the first one we did to, to go over, but anyway.
[CUSTOMER][NEUTRAL] Yeah, that's a broad plan.
[AGENT][NEUTRAL] Yeah, pretty big is it.
[CUSTOMER][NEUTRAL] Yeah, uh, yeah, that's, that's like listing everything basically.
[AGENT][NEUTRAL] At
[CUSTOMER][NEUTRAL] OK, yeah, you can send it through. I'll take a look at the documents.
[AGENT][NEUTRAL] OK, and, um, again, he's verified his callback number for you, [PII], should something happen, it's [PII].
[CUSTOMER][NEUTRAL] OK
[AGENT][POSITIVE] OK. Well, again, I would tell you to have a good day, but I'm just gonna tell you I'm praying for you and I hope you feel better.
[CUSTOMER][POSITIVE] All right thank you
[AGENT][POSITIVE] You're welcome. OK, so here we go.
[CUSTOMER][POSITIVE] Alright thanks.
[AGENT][NEUTRAL] Bye