AccountId: 011433970860
ContactId: 7b5a3f4b-676c-46bf-86a4-42624a7d607c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 852809 ms
Total Talk Time (AGENT): 213181 ms
Total Talk Time (CUSTOMER): 179758 ms
Interruptions: 1
Overall Sentiment: AGENT=0.5, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/01/7b5a3f4b-676c-46bf-86a4-42624a7d607c_20250401T14:32_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes, this is [PII], and I need to talk about my claim.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK sure I can help you with your claim. Do you have a policy number?
[CUSTOMER][NEUTRAL] 1579332
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And what's a good callback number today?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And just need to verify a few pieces of information. What is your birth date?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you. And your address?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you and then lastly your email address.
[CUSTOMER][NEUTRAL] Um, [PII].
[AGENT][NEUTRAL] Thank you. OK, and it was a, was it a claim for yourself?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Do you have the claim number or the date of service?
[CUSTOMER][NEUTRAL] Data service is 12 8 of 2024.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] What was the uh you have the bill charge on that with the total?
[CUSTOMER][NEUTRAL] Mm, I think it's 3700 and something.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] For an ER claim.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let's see what's going on.
[CUSTOMER][NEUTRAL] Well, they said that they needed an itemized bill and a discharge summary or whatever, but I sent the records the following day.
[AGENT][NEUTRAL] OK, you did.
[CUSTOMER][NEUTRAL] So they have an ERP. They have an item, yeah.
[CUSTOMER][NEUTRAL] It was 2 uploads that were sent.
[CUSTOMER][NEGATIVE] And they told me yesterday they saw the upload, so they don't understand why.
[AGENT][NEUTRAL] OK, let's see what we have.
[CUSTOMER][NEUTRAL] I think the first time I just sent a claim.
[AGENT][NEUTRAL] OK, let me pull up what we received. Let's take a look at it.
[AGENT][NEUTRAL] Yeah, I do see the 2nd submission here.
[AGENT][NEUTRAL] Uh, that was just received and processed.
[AGENT][NEUTRAL] Give me just a moment.
[CUSTOMER][NEUTRAL] You just, you just received it today?
[AGENT][NEUTRAL] No, it looks like we received it [PII].
[CUSTOMER][NEGATIVE] So why is it asking for an itemized bill and stuff?
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] Um, let me pull it up and see what.
[AGENT][NEUTRAL] What exactly is missing, um.
[AGENT][NEUTRAL] OK, so.
[AGENT][NEUTRAL] OK, I see the looks like.
[AGENT][NEUTRAL] Itemization for your hospital services. Let me see if we're missing a diagnosis, that might be what the issue is.
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Sorry, I'm just reading.
[AGENT][NEUTRAL] OK, um, let me, can I place you on a brief hold?
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] Sure. OK, thank you. Hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK, thank you so much for holding. Uh, what I'm gonna do, Ms. [PII], if you have time, I was gonna transfer you to our claims department. Um, I'll let them know I've verified all your information, give them that claim number and see if they can discuss in more detail what exactly they need, um, because I do show that you submitted the records, but I'm not, not quite clear on what else is needed. Is that OK?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Oh good.
[CUSTOMER][NEUTRAL] That's fine.
[AGENT][NEUTRAL] OK, hold on one moment, OK?
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Referring.
[CUSTOMER][POSITIVE] Good morning. Thanks for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hi, [PII], this is [PII] from the care team, and I've got a member on the line that has some additional questions about the claim status denial. Um, can I give you her information?
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] Um, the policy number is 01579332.
[AGENT][NEUTRAL] And I have verified all her information.
[CUSTOMER][NEUTRAL] And can you verify the name of the insured?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And which policy uh which claim number is you referring to?
[AGENT][NEUTRAL] Claim number is 3582495. So it looks like we received additional documentation from her just recently, but it was denied again and I guess so I.
[AGENT][NEUTRAL] I'm kind of confused as myself because
[AGENT][NEUTRAL] The itemized bill says that she had a fall. So I guess I don't know, do we have to have a specific diagnosis of fall or is is the itemized um description from the ER enough or?
[AGENT][NEUTRAL] That's what she's questioning, cause they, it looks like they filed a claim with the diagnosis of diabetes, but
[AGENT][NEUTRAL] It says in the notes that she fell, but like I said, I don't know if that's that's what's holding up the
[AGENT][NEUTRAL] Claim is that diagnosis or if those notes aren't enough.
[CUSTOMER][NEUTRAL] OK, let me just take a quick look here.
[AGENT][NEUTRAL] Or if you can just tell me, I can tell her so.
[CUSTOMER][NEUTRAL] OK. Yeah, let me see exactly what we have because I believe it is that we need a diagnosis code from like the medical provider, so let me just take a look and see what we've received.
[AGENT][POSITIVE] OK, OK, perfect. Thank you.
[CUSTOMER][NEUTRAL] OK. So, yeah, I see you have an itemized bill, but it does not have a diagnosis code on there. Let me see the other mail that we have.
[AGENT][NEUTRAL] Oh, that was past medical history. I see. OK.
[CUSTOMER][NEUTRAL] Yeah, so I'm seeing where it shows, yeah, that she had a fall, but it does not say li[PII] what she was diagnosed with, you know what I mean? Like what did she have a sprain, a fracture, you know, some type of like what, OK, she had a fall, but when you come in the emergency room, like what did you diagnose her with for the treating condition? Um, so let me see. I'm looking through the physical exam.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, OK.
[AGENT][NEUTRAL] That makes sense. I didn't, yeah, I didn't see an ICD 10 listed, so, OK.
[CUSTOMER][NEUTRAL] Yeah, so I would just say like, uh like, like I believe it's called a UBO4 like that document usually has uh uh oh you usually have like a, a diagnosis code on it.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, from the provider.
[CUSTOMER][NEUTRAL] Um, or, uh, like I said, she can also have, so I think it lists here an itemized diagnosis code or a super bill, any office notes or the admin and discharge summary, um, that has the actual diagnosis verified.
[AGENT][POSITIVE] OK, OK, perfect. I.
[CUSTOMER][NEUTRAL] For her accident claim.
[AGENT][NEUTRAL] OK, that makes sense. I was just making sure that it's not enough that they write that she fell, right?
[AGENT][NEUTRAL] They have to have the you have to we have to have the.
[CUSTOMER][NEUTRAL] Well, right, I mean,
[AGENT][NEUTRAL] OK. OK.
[CUSTOMER][NEUTRAL] Yeah, cause like the, in the policy, it's going to be for a specific like, like accident condition. It's not just, oh, did you fall? OK, you fell, but what happened for you fall for you to get treatment. What did they treat you for?
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK, perfect. OK. All right. I'll let her know and thank you so much for the information.
[CUSTOMER][POSITIVE] Uh, sure, yeah, you're welcome. Um, let me know if there's anything else you need.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][POSITIVE] Alright thanks bye bye.