AccountId: 011433970860
ContactId: 7fd6bab4-32b8-4354-8fef-b1e98cde8005
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 883820 ms
Total Talk Time (AGENT): 214147 ms
Total Talk Time (CUSTOMER): 451254 ms
Interruptions: 0
Overall Sentiment: AGENT=0.5, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/10/7fd6bab4-32b8-4354-8fef-b1e98cde8005_20250610T14:23_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yes, hi, [PII], can you give me one moment please? Um, [PII] at [PII].
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Sorry, I'm making a point. Do you need uh, what's that earlier? OK, let me see. Sorry, [PII], I know you're busy.
[AGENT][POSITIVE] You're OK.
[CUSTOMER][NEUTRAL] Um, [PII], [PII].
[CUSTOMER][NEUTRAL] OK, do you need a card? 1. Yes. Alright, you're all set. Yes sir. OK, sorry, um, so I'm calling about myself, um, my, um, I went to the dermatologist they submitted a claim. I received something from APL stating that office visits, I mean not office visits, sorry, this service is not covered when performed in a doctor's office or clinic.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] All it was was they burnt some little spots off. It was just like, you know, for precautionary in the office took them 2 seconds and I just called my insurance company and they said no, that it wasn't denied that they paid it.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It went towards my deductible, which then APL should pick up.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right, let me look into that. Um, what's your name and a good contact number in case we get disconnected?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes, yes, ma'am, it's [PII].
[CUSTOMER][NEUTRAL] The numbers [PII].
[AGENT][NEUTRAL] And what's your policy number?
[CUSTOMER][NEUTRAL] Um, it is 023-293-91.
[AGENT][NEUTRAL] Give me just a moment while I look that up.
[CUSTOMER][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] Actually, you know what? I have a different policy number. That's what it says.
[AGENT][NEUTRAL] I, I can look up the other policies afterwards.
[CUSTOMER][NEUTRAL] Oh no, that is yeah that is it 023, yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. Um, can I get you to verify your date of birth for me please, [PII]?
[CUSTOMER][NEUTRAL] [PII]. Do you need something? Yes, we will, we'll call you, um, a month ahead of time. Yes sir.
[AGENT][NEUTRAL] And the address and phone number that we have on file?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, and the phone number?
[CUSTOMER][NEUTRAL] Um, uh, it's maybe my cell [PII].
[AGENT][POSITIVE] OK, thank you so much and yes it was that one.
[CUSTOMER][POSITIVE] Mhm, OK, thank you.
[AGENT][NEUTRAL] All right, let me look here.
[AGENT][NEUTRAL] What was the date of service, do you know?
[CUSTOMER][NEUTRAL] To the right, 2 doors to your right, um, 2.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, let me see.
[AGENT][NEUTRAL] Give me just one moment while I try to look that up.
[CUSTOMER][NEUTRAL] Yes, yeah, sure.
[CUSTOMER][POSITIVE] Good morning.
[CUSTOMER][NEUTRAL] OK, Ms. [PII], let me see here. Address is [PII]. OK, you're all set. Just have a seat and [PII] will be out in just a moment. Yes ma'am.
[AGENT][NEUTRAL] Right, just one moment, my computer's going a little slow.
[CUSTOMER][NEUTRAL] That you're fine.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, I am seeing that it wasn't covered because it was performed uh in a doctor's office or clinic. Um, let me look into your policy.
[CUSTOMER][NEUTRAL] Yeah, because I mean the insurance company covered it, so I don't see why APL wouldn't.
[CUSTOMER][NEUTRAL] And I think the way they code it too because the ins the woman from the insurance company just told me said something about it was a surgical procedure something it I mean it was literally I don't know if you had things burned off before like a skin tag or you know a mole or something it was not cut or anything they froze it that's it.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, sometimes it depends, um, I don't know how they code it um but yeah, sometimes it depends, but.
[CUSTOMER][NEUTRAL] And I
[CUSTOMER][NEUTRAL] Yeah, well, I'm sure they code at the higher code so they can get more money out of it.
[AGENT][NEUTRAL] Is it, um, it wasn't for cosmetic purposes, it was for preventative. They did.
[CUSTOMER][NEUTRAL] Not at all. Yes, yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Just wanted to verify. Let me see here.
[CUSTOMER][NEUTRAL] When do you need to come back? 6 months? OK.
[CUSTOMER][NEUTRAL] That will be in December, any specific day or time?
[CUSTOMER][NEUTRAL] Not a Tuesday or a Thursday. OK.
[CUSTOMER][NEUTRAL] So that only gives us Monday and Friday because he doesn't work [PII], I can do 10:20.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Um, let's see if I have anything earlier. I have 8:40.
[CUSTOMER][NEUTRAL] I said 10:20. OK.
[CUSTOMER][NEUTRAL] What's the last name?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] You need a card?
[CUSTOMER][NEUTRAL] Hi
[AGENT][NEUTRAL] OK. Let me see.
[CUSTOMER][NEUTRAL] [PII], yes ma'am.
[CUSTOMER][POSITIVE] All right, you're all set thank you you too thank you.
[CUSTOMER][POSITIVE] Thanks to get them.
[CUSTOMER][POSITIVE] Oh, better not then, yeah.
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] So you're saying that your insurance, your primary insurance covered it as a surgery?
[CUSTOMER][NEUTRAL] Well that's what it was billed at that's I guess what that code is, is what she was when she was reading it off, but they did cover it, um.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] I have a reference number and everything. She said that it was definitely covered. What it went to a deductible.
[AGENT][NEUTRAL] OK, yeah, because I am seeing that um for this policy that you have a benefit of a surgery, but it's only in a hospital outpatient facility or free standing surgery center.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So that's probably why if they coded it as.
[CUSTOMER][NEUTRAL] OK, but I thought with APL what I was informed what I was told, I mean I've had this forever so I might be wrong.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] But I was told that as long as the doctor's office covers it, they pick it up anything that's as far as that goes towards my deductible.
[AGENT][POSITIVE] Great, um let me see if I can get someone from claims support to research this a little bit further for you, OK? Give me just one moment, OK?
[CUSTOMER][NEGATIVE] OK, and I'm sure what it is it's just the codes they use. I guarantee you that's what it is, but it was just simply, you know, they burned a few spots off and they weren't even cancerous they didn't send them in anything like that.
[AGENT][NEUTRAL] OK, give me just one moment.
[CUSTOMER][POSITIVE] Yes ma'am, thank you Miss [PII] yeah.
[CUSTOMER][NEUTRAL] Transferring.
[AGENT][NEUTRAL] I need a blanket. I'm cold.
[AGENT][NEUTRAL] Where's the um a moment.
[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. Um, I have a [PII] on the line, uh, policy number.
[AGENT][NEUTRAL] 02.
[AGENT][NEUTRAL] 32.
[AGENT][NEUTRAL] 9391.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And she has some questions about her claim that I'm not able to answer um the claim number is, uh, do you have it pulled up? I don't wanna bark it at you.
[CUSTOMER][NEUTRAL] What's the date of service?
[AGENT][NEUTRAL] Um, it's [PII], and it's the claim number ending in 4060.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It sounds
[CUSTOMER][NEUTRAL] And what was the question?
[AGENT][NEUTRAL] It sounds to me like, so she's wondering why it got denied instead of because it was a surgery, they billed it as a surgery, I guess, um, because she had some
[AGENT][NEUTRAL] Something on her skin burned off, and they coded it as a surgery, and then it got uh denied here and she was told that if her insurance helped pay for it, it would help go towards her deductible. Um, and I read her outpatient benefits to her that the surgery is supposed to be in an outpatient facility or freestanding outpatient surgery center. And she's, she's wanting to um get more research into that.
[CUSTOMER][NEUTRAL] OK, so like it was done in our office and she doesn't have benefits to cover anything in the doctor's office, but you can send her over.
[AGENT][NEUTRAL] Yeah, and that's what I said. Yeah, that's what I said. And it's, she said it wasn't cosmetic, but when, when you, when she um
[AGENT][NEUTRAL] Describes it. It sounds like it was cosmetic. They didn't burn skin tags off to get them diagnosed for anything. They just took them off of her. She said it was preventative. It, it sounds cosmetic to me, but I don't want to jump to conclusions when I can't read everything that she has.
[CUSTOMER][NEUTRAL] OK, alright, you can send her on over.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Right, and I will introduce you and your name is [PII], right?
[CUSTOMER][POSITIVE] Um, that's correct.
[AGENT][NEUTRAL] OK. Give me just one moment.
[AGENT][NEUTRAL] Right, [PII].
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][POSITIVE] I have [PII] from claim support on the line she'll be able to help you um further with that claim, OK?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] All right thank you so much.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] Good morning. Thanks for calling APO. This is [PII], and how can I help you? Hi, [PII], yes, I'm calling regarding a um something that was denied.
[CUSTOMER][NEGATIVE] Um, now the young lady that I was just speaking to, she said that it was denied because it was, um, done in an in office setting. It, it needs to be done in a surgical center or something. All this was was they burnt off or froze a few spots for precautionary measures at a dermatologist. It wasn't, they didn't cut, they didn't send anything in it was just a simple.
[CUSTOMER][NEUTRAL] Um, like I said, like, you know, you get your skin tags burn off or whatever. I don't understand why I would have to do that in an office set. I mean, I go anywhere other than the doctor's office.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] And I, I think really I'm sorry I think it's because the way they build it, the code they used.
[CUSTOMER][NEUTRAL] OK, and so where were, uh, this was done at the doctor's office, is that correct? It was, yeah, at Waters OKology. OK, and so, uh, maybe what she was trying to explain was that your policy only covers inpatient and outpatient services uh your policy does not provide benefits for any services performed in the doctor's office.
[CUSTOMER][NEUTRAL] No, that's not, that's not true. I've done this many a time I've had this policy for I don't know how many years.
[CUSTOMER][NEUTRAL] But every uh this policy that I have covers, um, it actually covers anything that's usually applied to my deductible as long as the my primary insurance covers it um then APL picks up anything that's applied to my deductible, but that's only if it's uh done in an inpatient or outpatient facility, not in a doctor's office.
[CUSTOMER][NEUTRAL] What's considered an outpatient facility, I mean.
[CUSTOMER][POSITIVE] I've I've never had this before and I've never I've done this before if you look back, I've done this before with another dermatologist and there was never any issue.
[CUSTOMER][NEUTRAL] I do not see anything that we have paid if that was for me it's been a while back but yes it was with Doctor [PII].
[CUSTOMER][NEUTRAL] The exact same thing.
[CUSTOMER][NEUTRAL] Do you have a data service? I don't know. I'd have to look back and find out now, but I, I mean this like I said this.
[CUSTOMER][NEUTRAL] No, I don't. Uh, this is the only one I've ever had since.
[CUSTOMER][NEUTRAL] Probably [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I am not seeing that we have paid anything in the doctor's office.
[CUSTOMER][NEGATIVE] What do you mean you've never, I mean I have stuff right here that's been paid.