AccountId: 011433970860
ContactId: 885acb09-474f-4172-89f3-58ea12565974
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 641599 ms
Total Talk Time (AGENT): 294319 ms
Total Talk Time (CUSTOMER): 200826 ms
Interruptions: 2
Overall Sentiment: AGENT=1.1, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/22/885acb09-474f-4172-89f3-58ea12565974_20250522T17:10_UTC.wav
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[AGENT][NEUTRAL] Afternoon. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yes, hi, um, I'm calling regarding a claim, uh, that was denied, and I, I, and I know for a fact that it shouldn't have been, so I just wanna verify the information with you guys.
[AGENT][NEUTRAL] OK. Are you the insured or are you calling on behalf of a provider?
[CUSTOMER][NEUTRAL] No, I'm, I'm the insured. It's for my son.
[AGENT][NEUTRAL] Uh yes, ma'am. I can help you and who am I speaking with?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you, Miss [PII]. What is a good callback number for you please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you and what is your policy number please?
[CUSTOMER][NEUTRAL] It is 02141813.
[AGENT][NEUTRAL] OK, thank you. One moment while I get your information pulled up and once I do, Ms. [PII], I will need to verify several things with you. First, for security and then also any information that's provided will be a verification of benefits and not a guarantee of payment. So just one moment please.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so first off, Ms. [PII], if you could verify the primary policy holder's name and date of birth and then your date of birth.
[CUSTOMER][NEUTRAL] [PII]. His date of birth is [PII], and my date of birth is [PII].
[AGENT][NEUTRAL] Thank you. And then your son's name and date of birth?
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][NEUTRAL] Thank you. Your home mailing address?
[CUSTOMER][NEUTRAL] It is [PII]. That's actually our old one. I don't know if you guys have the updated one.
[AGENT][NEUTRAL] OK, so that is still the address that we have on file, but Mr. [PII] would have to update that. We can only update that with him.
[CUSTOMER][NEUTRAL] But it
[CUSTOMER][NEUTRAL] Yeah, OK, that's fine. I thought that the employer would do that, but I'll have him call, that's no problem.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, and he will need to make sure that it's updated with the employer too, otherwise it will even if we make a change with him if it comes across with this address still on there, it's gonna override our change.
[AGENT][NEUTRAL] So he definitely needs to make sure.
[CUSTOMER][NEUTRAL] Yeah, I don't know why. I, I'm, I'm pretty sure he, yeah, I'm pretty sure he had updated it with the with his HR but that's why I find it weird.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Yeah if he did if he has updated it there, um, then he can call us and we'll be happy to get it updated in our system as well.
[AGENT][NEUTRAL] And then if you could please verify Mr. [PII]'s phone number?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, no problem.
[CUSTOMER][NEUTRAL] I'm sorry, can you repeat that?
[AGENT][NEUTRAL] What is Mr. [PII]'s phone number?
[CUSTOMER][NEUTRAL] Phone number is [PII].
[AGENT][NEUTRAL] OK, thank you and then what is the date of service that you're calling about for [PII]?
[CUSTOMER][NEUTRAL] It was [PII].
[AGENT][NEUTRAL] I'm so sorry. [PII], what date? [PII]?
[CUSTOMER][NEUTRAL] The first, the first, yeah, no, no, the [PII], [PII]. Yeah.
[AGENT][NEUTRAL] First, OK, OK.
[AGENT][NEUTRAL] And what was the bill amount for that data service?
[CUSTOMER][NEUTRAL] It was 350, I believe.
[AGENT][NEUTRAL] Give me just a moment.
[AGENT][NEUTRAL] And what was the facility or the provider's name for this claim, Ms. [PII]?
[CUSTOMER][NEUTRAL] It was Nicholas Children's Hospital.
[AGENT][NEUTRAL] OK, so now we do show a claim on file for Nicholas Children's Hospital for him, but the total bill amount is much more than the, was the amount that you just gave me.
[AGENT][NEUTRAL] Your portion that was left.
[CUSTOMER][NEUTRAL] I mean, ma'am.
[CUSTOMER][NEUTRAL] Maybe that's the because that's the co-payment um let me see, let me look at the file that I submitted. Hold on, give me one second.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] The explanation of benefits.
[CUSTOMER][NEUTRAL] The amount billed, the total bill was 2,97143.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK. So I do have this claim pulled up. I can see that it was denied.
[AGENT][NEUTRAL] This shows that the denial reason on the claim, Ms. [PII] was policy provides no benefits for the treatment of conditions other than a sickness or injury as defined by the policy.
[CUSTOMER][NEUTRAL] Yeah, that's what I don't understand because I took him to the ER for sickness. I like the other ones were, and, and what's funny is, he had, he had like 3 back to back because he was very sick and we had to keep going back. The other two, and, and it was mostly for the same reason, like, so that's why I don't understand, maybe it's a confusion with the diagnosis code that [PII] provided.
[CUSTOMER][NEGATIVE] Um, but it was a sickness, like it's, it was, we took him to the ER to the emergency room. It should be approved, uh, I, I don't, I don't understand.
[AGENT][NEUTRAL] OK, so
[CUSTOMER][NEUTRAL] Is it because of the diagnosis so?
[AGENT][NEUTRAL] I can only, whatever the, um, it doesn't specifically say the diagnosis. That is the remark that I can see, um.
[AGENT][NEUTRAL] It's the same as what you can see. Give me just a moment. I'm sorry, go ahead with your question while some other information is loading for me.
[CUSTOMER][NEUTRAL] OK, so, so.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] No, I was just gonna ask, like, like.
[CUSTOMER][NEUTRAL] Yeah, I was just gonna ask like what can I do? because I know that this, this should be uh approved. um I feel like there's a miscommunication or misinformation. Um, so I don't know like what would be the next step because I would have to resubmit this claim.
[AGENT][NEUTRAL] OK, so let me
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Now,
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] OK. So a couple, you have a couple of options, Ms. [PII]. I could try and, I can send or either transfer you to someone who could clarify on the, the question you had about the diagnosis.
[AGENT][NEUTRAL] You may also file an appeal on the review.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And an appeal must be filed within 180 days from the date of the decision.
[AGENT][NEUTRAL] And this claim was processed on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, um, what, what's the fastest way, uh, which is the fastest option?
[CUSTOMER][NEUTRAL] I mean, do you think it's worth it for me to to speak to somebody to maybe clarify what's going on, or do you think I should just appeal?
[CUSTOMER][MIXED] Regardless, I'm appealing. I just don't know if maybe, maybe speaking to somebody.
[AGENT][NEUTRAL] On it, yeah.
[AGENT][NEUTRAL] Right. And if they could, you know, um, maybe someone could give you a little more clarification on this remark again, because the remark, you know, I see what you see on your explanation of benefits.
[AGENT][POSITIVE] But I would be more than happy to, you know, to connect you or to ask someone to call you, whichever is more convenient for you.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Yeah, you can transfer me if that's possible.
[AGENT][POSITIVE] OK, well, I'll be happy to try and do that. Uh, is there anything else, Ms. [PII], that I could help you with first?
[CUSTOMER][NEUTRAL] No, that, that's pretty much it.
[AGENT][POSITIVE] OK, well then thank you again for calling APL and I hope that you have a nice rest of your afternoon.
[CUSTOMER][NEUTRAL] Things likewise.
[AGENT][POSITIVE] OK, thank you so much. So one moment please.
[CUSTOMER][NEUTRAL] Referring.
[CUSTOMER][POSITIVE] Good afternoon. Thanks for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hey [PII], it's [PII]. How are you?
[CUSTOMER][POSITIVE] I'm good. How are you?
[AGENT][NEUTRAL] I'm all right, thank you. So I have an insured's mother on the line. She was calling regarding a denied claim for the child.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] What's the policy number?
[AGENT][NEUTRAL] And I've, it is 214-1813.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The claim number is going to be 35,980.
[CUSTOMER][NEUTRAL] What's that part number?
[AGENT][NEUTRAL] 2 part I mean the claim is for part 3.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] The day, the claim number is 3598064.
[CUSTOMER][NEUTRAL] 35,980 OK.
[AGENT][NEUTRAL] Mhm. And I've gone over the remark with her. I've explained the um appeal process, but she's wanting more clarification on what that remark code means.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, I can help her with that.
[AGENT][NEUTRAL] And she's fully verified, and this is [PII] on the line.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] And her call back number [PII], let me see, hold on, my phone's not up. It's the phone number that's up on the screen that you should see.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Yes ma'am. That's it.
[CUSTOMER][POSITIVE] OK, alrighty.
[AGENT][POSITIVE] OK. All right, [PII]. Thank you so much. OK.
[CUSTOMER][NEUTRAL] Bye.
[CUSTOMER][NEUTRAL] Alright.
[AGENT][NEUTRAL] Bye-bye.