AccountId: 011433970860
ContactId: 7f804eab-03dc-4829-b0bf-e81ecf6353db
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 807119 ms
Total Talk Time (AGENT): 512908 ms
Total Talk Time (CUSTOMER): 279298 ms
Interruptions: 6
Overall Sentiment: AGENT=0.3, CUSTOMER=-0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/18/7f804eab-03dc-4829-b0bf-e81ecf6353db_20250218T18:34_UTC.wav
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[AGENT][POSITIVE] Thank you for contacting APO. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], uh, my name is [PII], and um, I'm reaching out because I submitted several claims which are 90% of them are the urgent care $50 that I need to pay every time I take my son to Nicholas Urgent Care.
[CUSTOMER][NEUTRAL] And they seem to all be denied, but according to my um.
[CUSTOMER][NEUTRAL] Plan administrator at work, the, the urgent care fees that I pay should be reversible so I wanted to, I mean, not go back and forth in emails. It seems like it's very easy to, to just say no thanks on an email, so I wanted to speak with somebody to understand.
[CUSTOMER][NEGATIVE] Why one person, you know, my plan administrator is telling me this and then on your side you guys are declining my um.
[CUSTOMER][NEUTRAL] I guess my claim.
[AGENT][NEUTRAL] OK. Well, let's look at uh at your policy and, and see, uh we can start pulling those claims up. What is your policy number, please?
[CUSTOMER][NEUTRAL] Um, can I give you my social because I'm driving?
[AGENT][NEUTRAL] OK, and what is your social security number, please?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. And if I could just verify your date of birth and a phone number, please?
[CUSTOMER][NEUTRAL] Of course, um, [PII], oh my [PII], that's going crazy.
[CUSTOMER][NEUTRAL] I was gonna tell you the date today, uh, so [PII], and my phone number is [PII].
[AGENT][POSITIVE] OK, I do appreciate that. So I'm just looking this up now.
[AGENT][NEUTRAL] Or
[CUSTOMER][NEUTRAL] Sure
[AGENT][NEUTRAL] And this is for your, for your son. OK. Let's see what we have here.
[CUSTOMER][NEUTRAL] Correct, [PII], I think I submitted uh several because unfortunately last year, um.
[CUSTOMER][NEUTRAL] He was
[CUSTOMER][NEUTRAL] A regular at the urgent care due to that.
[CUSTOMER][NEUTRAL] You know, random things that were happening, yeah.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Yes, of course. Let's let's look and see what we, I have several of them here. So what I'm doing is I'm just looking at each individual one.
[AGENT][NEUTRAL] Um, let's see this first one, OK.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] So it looks like um.
[AGENT][NEUTRAL] The urgent care visits, uh, if I'm correct in in seeing this, um,
[AGENT][NEUTRAL] We had uh
[AGENT][NEUTRAL] December, September.
[AGENT][NEUTRAL] Those those OK so let's see what we have here.
[CUSTOMER][NEUTRAL] So they were uh 2 in September if I recall 1 in December. I, I don't recall all the dates obviously you have the, the claim in front of you. In September I had to take him one day and then the following day again.
[AGENT][NEUTRAL] Of course.
[CUSTOMER][NEUTRAL] Um, and then the other ones were like separate other occasions, but in September I remember I had to because I came back from vacation, he had like this terrible rush, so I took him for the rash and it was just a rash, and they said, oh yeah, just put his cortisone and all is good. We went back home, all was good. The next day he wakes up with a terrible fever and I panicked that it might be malaria because I was in [PII].
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] So I took him again and that's why they're like back to back two days.
[AGENT][NEUTRAL] Right, of course, of course. No, that's, that's fine. So the, the, um, first of all, um, uh,
[AGENT][NEUTRAL] The, the charges aren't, aren't denied. So whenever we have something like this, um, when, whenever we have something like this, what we're looking for is a diagnosis code. So it looks like there's several of these, um, where we are trying to get the diagnosis code, uh, from, um, uh, from you. It just and, and I know that it's, it's difficult, uh, to, to, to determine what a diagnosis code is if you're not in medicine. I do we do understand that.
[AGENT][NEUTRAL] So what we can do is, um, what we ask that you do is you can fax us uh something or or you can send it. It looks like you may have sent this through uh our online service. I'm not really sure here yeah it looks like he went through our online service so if you could um just let us know you know like uh let us know what the services were for. So let me, let me go back to the first one here, um, where we have uh uh [PII], excuse me, [PII].
[AGENT][NEUTRAL] Um, let's just say, uh, you could say like, uh, for these visits, [PII], [PII], [PII], I took [PII] in, um, because he had a rash or because he had, um, coughing or, you know, something like that. If you could just describe the symptoms to us, then we will look up the diagnosis codes and then we can finish paying the claims.
[AGENT][NEUTRAL] So the claims aren't denied. What they are is that they, we, we have to have a diagnosis code for each service. Insurance is just like that, you know, your major medical is the same way. They have to know what the, what the event was for. So, um, because, uh, what we're asking for is the diagnosis code and because we, we realized that that's difficult to find, all you have to do is describe for us.
[AGENT][POSITIVE] You know, he, we, I took [PII] into the urgent care for these dates of service because um you know, whatever just described to us what it was, you don't even have to go into great detail.
[CUSTOMER][NEUTRAL] But I know that that.
[CUSTOMER][NEGATIVE] First day in uh [PII]ember was for a rash. The second day was a high fever, and then all the rest were fever because like when the fever goes like ridiculously high, you know, I, I panic usually because you know how I tell you.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] I, I, yeah, I'm a mother. I do understand. Yeah.
[CUSTOMER][NEGATIVE] If it goes too high, it could cause brain damage and you know shivers and whatever else so like when I see it, I panic and I take him so obviously that's why he has insurance.
[AGENT][POSITIVE] Absolutely, yes.
[AGENT][NEUTRAL] No, that's fine.
[AGENT][NEUTRAL] Well, no, that's, that's fine. As I, as I mentioned before, I'm, I'm a mother. I, I do, I completely understand it. I, I had my kids. We, we practically had a wing of the hospital named after us at one point. So, um, the thing is, is that, um, all you have to do is just tell us, you know, and really you can do it like you can do it like this, you said that one of them was for a rash. You can say on this date of service it's for a rash on all the other dates of service. It's because he had a fever and then what we will do.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] is we will look up the diagnosis code for a fever and for everything else that follows we will put, you know, that that's all that we're looking for. So there yes, you do get uh this is part of your, your insurance, um we do have uh the stuff, um, you know, that we need, we have everything that we need except for the reason that [PII] went in for those particular services. So, um.
[AGENT][NEUTRAL] If you could just go back through the portal as you have before, please ma'am.
[CUSTOMER][NEUTRAL] I, I told.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I thought that on those forms when I submitted them it says like uh what the doctors did so I I felt like it it.
[AGENT][NEUTRAL] Well, yeah, what they did, but not what they, yeah, but it's, it's what they do is, we, we don't, we know what the doctors did, but we don't know what it was for. So, um, on the, on the services on the paperwork, we just need to know what it was for. So if you um you can
[CUSTOMER][NEUTRAL] OK, so I will reopen the form or what what do I need to do now?
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Well, what you can do is you can go back in and and when you go back into the online portal you'll see each one of the claims, you'll see where it says um DM 82.
[AGENT][NEUTRAL] Um, on there and for those dates of service, you can just, uh, what you can do is you can just go back in and um you can fill out that form. There is a, a, a sort of a claim form and on there um you can put, you can just type in or write um.
[AGENT][NEGATIVE] These dates of services are for a rash. These dates of services are for um fever. This date of service is because, you know, we had a, I don't know, whatever else a small child has. Yeah, whatever it is that it was for. And then what you could do is submit that and then what we will do.
[CUSTOMER][NEUTRAL] Whatever they do.
[AGENT][NEUTRAL] If we will look up the diagnosis code for each thing that you put down there and then we will go back to the claims, all the paperwork that you've already submitted, and then we will start paying out the claims. But um yeah, if you, if you will just do that for us um and then the next time you turn in a claim for [PII], all the paperwork that you sent in was great, but you can just write down on the paperwork on the EOB, you know, this data service is for this.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] And you can have 27 different dates of, of service with a, with a rat, you know, high fever, we get that.
[CUSTOMER][NEUTRAL] OK, so
[CUSTOMER][NEUTRAL] Can I
[CUSTOMER][NEUTRAL] Can I send you an email with all of that or no?
[AGENT][NEUTRAL] Um, yeah, um, yes, well, wait, no, I don't think so. I don't know that they'll, you could try sending it in on an email, um.
[AGENT][NEUTRAL] There should be a way to go in online on the online portal and talk to somebody through an email service.
[CUSTOMER][NEUTRAL] Because when I went on the, when the online portal when I did this.
[CUSTOMER][NEUTRAL] I mean I went now because it says uh process that's why I presume that nothing's happening because nothing's processed. No, I didn't receive any email, no feedback, no nothing, right? So that's why I'm curious cat and I'm calling you.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Right.
[AGENT][NEGATIVE] Oh, you didn't get your, you didn't get your email? I exceeding your explanation benefits because one was mailed out. Now there's, here, hold on just a second, because that's, that is serious, um.
[CUSTOMER][NEUTRAL] No, I mean maybe in the mail I'll receive it, but you're telling me the online portal is my place to go.
[AGENT][NEUTRAL] Oh yeah, it was all done on the [PII]. 0, you didn't get it yet because it was all done on the [PII] of this month, so it's, it's, it's in the, it's in the mail to you, um, but, uh, on the online portal, so, so all of these explanation of benefits are gonna be on there, on, on they've been mailed to you, um, and they all went out on the [PII] or the [PII], which is last Thursday.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] So, um, you, there should be uh a place on there where you can set where you can contact us uh by email on the online portal. If not you can just go ahead and and where it says start a claim and you can just um you can do it that way.
[AGENT][NEGATIVE] It's just that we can't take it over the phone unfortunately.
[CUSTOMER][NEUTRAL] No, what I was saying is that.
[CUSTOMER][NEUTRAL] I do not know how to go back and do the.
[CUSTOMER][NEUTRAL] I guess readjust or rewrite what is it that you're asking me to do.
[AGENT][NEUTRAL] Oh, you don't, you don't have to do that. Um, all you would have to do, let's see, let me get into the, you, you don't have to go back in and readjust any of the paperwork. We're, we're, we don't want you to do that. Um, you, you couldn't do it anyway. Uh, it's not set up for, for people to do that, but that's fine.
[CUSTOMER][NEGATIVE] I understand, but like when I have my 3 submitted things, there's no way for me to edit and put anything like those additional items that you're asking me to put, I guess that's what I'm trying to say.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Sure. OK. OK. OK, let's see.
[CUSTOMER][NEUTRAL] So the only way that I could see how I do what you're asking me to do to do it through there is to resubmit the same thing, but then on each paper I write something.
[AGENT][NEUTRAL] Yes, uh, let's see, supported, OK, OK.
[AGENT][NEUTRAL] So, when um,
[AGENT][NEUTRAL] When you go in, uh, really the only thing that you would need to do is, um, when you go back in to uh the um the OSC or when you go back into our online service center.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] There's a place that says my claims and when you uh click um the the thing to start now it should pull up a claim form it should it should pull up a claim form that allows you to um.
[AGENT][NEUTRAL] To fill it out.
[CUSTOMER][NEUTRAL] To submit a new claim.
[AGENT][NEUTRAL] Just, just the claim form, just the claim form itself. Now on the claim form, um, it you, it will ask you the dates of service and things like that, but there is a place on there.
[AGENT][NEUTRAL] Well you can type type in um what you're submitting a claim for so it will, it will have a space and it will say dates of service and the sorts of things and you can actually put in.
[AGENT][NEUTRAL] The data service that we're talking about and it will also say um uh claim is for and and you can put on there um sometimes people put the name of the doctor or whatever but that's where you could actually write in what the claim is for. So there is a spot on the claim form itself, let's see if I can find it.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK, I will, I will sit in front of the computer and do it and then if I have questions I'll call again.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yes, yeah, that, but there is a place on there that you can that you can just go ahead and and um uh put write it down on there and this will be on our online er so but so you don't have to go back in and resubmit all the paperwork. It's not necessary to do that.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Now, is this the only thing that we're looking at? Oh, is there anything else at all that I can help with?
[CUSTOMER][NEUTRAL] OK, I'll take a look.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] No, that was all. I just couldn't figure out how.
[CUSTOMER][POSITIVE] How to do this thing. OK, perfect. Thank you so much. I will review it when I start. Alrighty, my dear, thank you.
[AGENT][POSITIVE] OK, thank you.
[AGENT][POSITIVE] OK, thanks for contacting AP have a good.