AccountId: 011433970860
ContactId: 82bcfbeb-7e6a-4bea-bbc9-c79f0407cd0d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 476880 ms
Total Talk Time (AGENT): 136006 ms
Total Talk Time (CUSTOMER): 264781 ms
Interruptions: 0
Overall Sentiment: AGENT=0.5, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/14/82bcfbeb-7e6a-4bea-bbc9-c79f0407cd0d_20250414T20:17_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, I'm calling in regards to um a claim I had submitted and I just received the um I guess y'all call them like an EOB in the mail.
[AGENT][NEUTRAL] OK. Do you have your policy number?
[CUSTOMER][NEUTRAL] Sure it's um the claim number is 3587628 and the policy number is 02271308.
[CUSTOMER][NEUTRAL] And they have a reference number also.
[AGENT][NEUTRAL] OK, was it for yourself?
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] OK. And can I get your date of birth?
[CUSTOMER][NEUTRAL] Sure, it's uh [PII].
[AGENT][NEUTRAL] And your name?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Uh, just need a few more pieces of information. Do you have a good callback number in case we get disconnected?
[CUSTOMER][NEUTRAL] Sure, [PII].
[AGENT][NEUTRAL] OK, and your address?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, last thing, your email address.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, let's see what we've got here.
[CUSTOMER][NEUTRAL] The date of service is [PII].
[AGENT][NEUTRAL] OK, and how can I help you with that claim?
[CUSTOMER][NEUTRAL] Because on my policy when I got my policy I was told for a uh surgery we we we get a $1000.
[CUSTOMER][NEUTRAL] You get one surgery benefit for $1000 and the in-office surgery is $500. This was not in office, this was at a surgery facility.
[CUSTOMER][NEUTRAL] Like I went under general anesthesia and everything.
[AGENT][NEUTRAL] OK, let me look at your benefits.
[CUSTOMER][NEUTRAL] The um
[CUSTOMER][NEGATIVE] The in office is one per year for 500 and that one I had submitted one of my claims for [PII], which was an in office debridement. That one was y'all paid the $500 which is correct, but this one y'all only paid 500 and I was told I would get 1000 when I had surgery.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] One time a year.
[AGENT][NEUTRAL] Yeah, I see that um let me pull up the claim real quick hold on one moment.
[CUSTOMER][NEUTRAL] Now when they gave me the printout with the CPT code like because y'all y'all make it where you have to have the CPT code and the diagnosis codes and all that stuff.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] It, it printed on their letterhead to show, you know, Hagen by Simon ENT clinic, but I mean I have the EOBs from like Blue Cross and stuff, you know, showing like the facility, the anesthesiologist, all those people too for that day.
[AGENT][NEUTRAL] OK. I think that's where the problem.
[CUSTOMER][NEUTRAL] To show the so.
[AGENT][NEUTRAL] Yeah, so, yeah, I see the clinic.
[CUSTOMER][NEUTRAL] Yeah, but in order to get uh.
[CUSTOMER][NEUTRAL] But in order to get the CP like in order to get the details y'all need that's the way they had to print it out because like a Blue Cross EOB doesn't give the details y'all need it gives just a blanket data service.
[CUSTOMER][NEUTRAL] You know, surgery, it says surgery and then it says the amount and it says what they paid. So that's why I got them to give me a printout of like a detail from their system. So I think that's where the confusion's from.
[AGENT][NEUTRAL] Well, the EOB from Blue Cross Blue Shield has the provider as [PII].
[AGENT][NEUTRAL] So it doesn't have a hospital name.
[CUSTOMER][NEUTRAL] He's a doctor before.
[AGENT][NEUTRAL] OK. So,
[CUSTOMER][NEUTRAL] I can get you the EOB for the hospital, the anesthesia.
[AGENT][NEUTRAL] Yeah, that would be, that would be what we would need. Um, you can either get the EOB or you can ask the hospital to provide you a UBO4. That's basically the actual claim.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah, I have called and left a message, but I'm just waiting to hear back, but I could so if you would take the the uh the EOB from [PII] that matches that same date, I can show you that they they had an anesthesia charge, a hospital charge for that same day.
[AGENT][POSITIVE] OK, yeah. If you can get that to us, that would be really helpful. Um, let me see though, I just wanna make sure.
[AGENT][NEUTRAL] OK, let's see. So we, we do need the diagnosis code and the procedure codes and that's, I don't, so the EOB I don't think that's gonna have that. It's not gonna have.
[AGENT][NEUTRAL] Because the EOB just says.
[CUSTOMER][NEUTRAL] Even though you already have it.
[AGENT][NEUTRAL] Well, we, what we paid this claim off of was the statement from the clinic because it had what we needed, which was procedure codes and diagnosis.
[AGENT][NEUTRAL] So we, we would need documentation that includes that, um, and that it shows that it was actually rendered at a hospital.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] That's why I mentioned the UBO.
[CUSTOMER][NEUTRAL] OK, well, I guess I'm happy to
[CUSTOMER][NEUTRAL] Yeah, I'm gonna have to call them again I guess um I I just it's all gonna be the same. I just don't.
[CUSTOMER][POSITIVE] OK, I'll get it though so I can get my full benefit.
[AGENT][NEUTRAL] OK, sorry about that. Yeah, we just have to have the exact documentations.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I don't see if you have the same date of service and everything you already have one diagnosis from the doctor. Why, why you have to have it from everybody else, but that's OK. I'll call and get it.
[AGENT][NEUTRAL] OK. Anything else I can help with?
[CUSTOMER][POSITIVE] No, that's all. If there's ever like a punch list for somewhere or whatnot, if y'all could reach out to the insurance companies and ask like Blue Cross Blue Shield and them to start putting the CPC codes and diagnosis codes for y'all, that would be amazing because that would be so much easier to submit your EOB from your insurance.
[AGENT][NEUTRAL] Well, part of the reason they don't do that is because of HIPAA, so they won't put diagnosis codes or um CPT codes because of HIPAA. That's why.
[CUSTOMER][NEGATIVE] But I'm saying like if you sign on to your account because like I didn't go on my Blue Cross right now and print out whatever um it just makes it so much easier because you have to call all these places and get printouts and a lot of these places you have to go pick it up because they won't email it to you or they won't mail it to you because uh you know, the same reasons and stuff so it just makes getting all this information very time consuming.
[AGENT][POSITIVE] Yeah, I'm sorry about that.
[CUSTOMER][NEUTRAL] Cause you can't just get it on the day, day of the first, you know, day of the procedure, so.
[AGENT][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK, so where do I send this to? and how do I get it attached?
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] You can just reference the claim number when you send it and do you want to mail it or fax it?
[CUSTOMER][NEUTRAL] I wanna fax it please.
[AGENT][NEUTRAL] OK, fax is 877.
[AGENT][NEUTRAL] 3659423
[AGENT][NEUTRAL] Um, or of course, you can upload it to your portal. That would work as well.
[CUSTOMER][NEUTRAL] But I don't think it lets you reference the claim number though.
[AGENT][NEUTRAL] I mean, like if you wrote it on the documentation.
[AGENT][NEUTRAL] That you're submitting, yeah.
[CUSTOMER][NEUTRAL] Oh, OK, OK.
[CUSTOMER][POSITIVE] OK, OK, alright, well thank you so much. I will definitely get that information.
[AGENT][POSITIVE] OK, thank you for calling APL. I hope you have a good day.
[CUSTOMER][NEUTRAL] You too bye bye.