AccountId: 011433970860
ContactId: 79e51d35-a623-4d6f-adec-2ae36da20567
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 432420 ms
Total Talk Time (AGENT): 222763 ms
Total Talk Time (CUSTOMER): 207526 ms
Interruptions: 3
Overall Sentiment: AGENT=0.7, CUSTOMER=1.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/13/79e51d35-a623-4d6f-adec-2ae36da20567_20250313T15:53_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling ATO. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey, good afternoon or good morning. I'm sorry, I should say this is [PII], and I'm calling um with questions uh regarding um uh benefits and explanation of benefits for services for my husband [PII]. The claim number is 357-0402.
[AGENT][NEUTRAL] OK, so we were just needing a clarification regarding this claim.
[CUSTOMER][NEUTRAL] Well, I've made the claim and I received an explanation of benefits. However, on the front page, um, there's some remarks noting that um the policy provides benefits for transportation to the place of treatment when it's at least 50 miles and it says to, um, that.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] It looks like that our legal residence is less than 50 miles from the place of the current treatment, which is incorrect because we live in [PII], and the service was in [PII], which is.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 3 hours drive north for us and then the other one is in order to give consideration to this state of service, we'll need a fully itemized hospital facility billing with all charges fully identified.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Um, and then it asks that again, um, for the diagnosis code and then it says with this check the maximum benefit payable for this date of service has been met so I'm just uncertain if you need more information if the claim has been um.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Completed if there's additional information that you need I'm just not sure.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] I understand and it is very confusing and we can definitely take a look at all of that so I can explain that a bit better um and I'm so sorry you said your name was [PII], is that right?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] [PII] Yes.
[AGENT][NEUTRAL] OK, and then before we go any further, can I get a good call back number from you please in case we're disconnected?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Sure my phone number is [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] OK, thank you so much for that and is [PII] available that I could speak with him to verify his information?
[CUSTOMER][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] He is not. I have been handling this since the beginning 4 years ago. I think he had to talk with someone to make sure that it was OK that you guys spoke with me, so that should be noted on the account. I've had to call him quite a few times over the last 5 years. So, um, if you need to speak with him, I can certainly.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] I understand
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, give me your number mhm.
[AGENT][NEUTRAL] Go ahead, I'm sorry.
[AGENT][NEUTRAL] Yes, so we have had uh to be a bit stricter on our, yes, so we have had to be a bit stricter on our, um, you know, with, uh, privacy and security and such so I don't see you listed typically with um the verbal you know if we were to talk to him it's simply for that one call so.
[CUSTOMER][NEUTRAL] I was just gonna say I could give you his number and you could call it.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] What I would recommend, um, especially if you're the one who handles this most of the time, is, um, [PII] can fill out a, uh, third party authorization form essentially giving you full permission uh we wouldn't have and that would be permanent and we would be able to see that on the account so we wouldn't need to talk to him every time.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] OK, um, is there a place that I can go to get that form for you guys?
[AGENT][NEUTRAL] Absolutely, yes, so it is on our website um it's [PII].
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And there's a section that you'll see at the top where it'll say uh claims and forms or claim forms um it should be close to the top just authorization form.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And that can be um you know that can be emailed to us uh filled out digitally or you can print it, whatever is easier for y'all.
[CUSTOMER][POSITIVE] Perfect.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Alrighty, I'll work on that um and get that back to you guys and then follow up with you on this uh other information to uh get the claim.
[AGENT][NEUTRAL] Sure and I can absolutely and while I can't of course at the moment disclose anything specifically regarding this claim I can explain that the reason you're seeing all of those different notes at the bottom um they are all for the different things that we've received and that's where I think a lot of the confusion can come in so while we might have paid benefits for certain items or certain items might need more information, does that make sense?
[CUSTOMER][NEUTRAL] Yes it does it's more or less kind of a history of what you guys have received and what's going on to the date.
[AGENT][NEUTRAL] Right, and it's not as a whole the claim got denied some of them might have said denied, but it could also be that we just need more information.
[CUSTOMER][POSITIVE] Sure, no problem. I'll be glad to get that um done for you. It may be next week, but I'll certainly get it.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Of course, absolutely, um, do y'all have access to our online portal?
[CUSTOMER][POSITIVE] Yes, I do that that's how I actually um upload everything so yes.
[AGENT][POSITIVE] Awesome, yes, that's what I was gonna say. That's easiest and quickest way to get that information to us. Alright, well I sure appreciate your understanding with the situation [PII]. Did you have any other questions for me? Any anything else I could help you with?
[CUSTOMER][NEUTRAL] Yeah, I
[CUSTOMER][NEUTRAL] No, um, there, the claim won't be closed or finalized until, um, these, these have been addressed, correct?
[AGENT][NEUTRAL] Oh no, no, it's, it doesn't work like that, um, so even if a specific item says denied, that's not a hard no there's no timely filing limit at all so if any additional information was needed, um, then we, you could uh send that to us just whenever you can. That's perfectly fine.
[CUSTOMER][NEUTRAL] OK, alrighty, um, can you tell by looking if there's any like outstanding information that you guys are still waiting for or I mean, um, based on this explanation.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, especially since.
[AGENT][NEUTRAL] Sure, uh just going off of what you read to me, um, like the itemized statements, um, that need the diagnosis and procedure codes, that's going to be essentially what we need across the board for most anything, um, so and you would be able to get that from the provider or facility wherever treatment was received they'll have that information.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Well, I will try again um I thought that I had submitted all that information, but I will certainly try again.
[AGENT][NEUTRAL] It can be very confusing um especially you know sometimes it might look like those specific codes and they may not be that's why I would just recommend going straight to the provider and telling them this is what you need because then they'll be able to definitely give that information to you.
[CUSTOMER][POSITIVE] OK great thank you so much I appreciate your help.
[AGENT][POSITIVE] You are very welcome. Yes, ma'am. I hope you have a great rest of your day.
[CUSTOMER][POSITIVE] You too thank you bye bye.
[AGENT][POSITIVE] Thank you. Bye bye.