AccountId: 011433970860
ContactId: 92f977a4-3b08-4d1f-9edf-c6f558011ab8
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 829000 ms
Total Talk Time (AGENT): 425749 ms
Total Talk Time (CUSTOMER): 135825 ms
Interruptions: 0
Overall Sentiment: AGENT=0.3, CUSTOMER=-0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/04/92f977a4-3b08-4d1f-9edf-c6f558011ab8_20250604T20:54_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, I'm calling because I received a text message that my claim was processed, but I can't.
[CUSTOMER][NEUTRAL] Find the information online, like it's not logging in, so I was wondering if someone can tell me.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] The information on that?
[AGENT][POSITIVE] Yes, I can definitely help you with your claim status. Um, and I do want to apologize. We're having a lot of issues with our website since the new launch on Friday, so IT is working on that. That's probably why it's giving you such a hard time. Um, so I apologize for that, but I'll be more than happy to help you with your claim. Um, may I have your name?
[CUSTOMER][NEUTRAL] On that claim.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And [PII], may I have a good contact number in case we're disconnected and your policy number?
[CUSTOMER][NEUTRAL] Yeah it's [PII].
[CUSTOMER][NEUTRAL] Um, the policy number is 0261.
[CUSTOMER][NEUTRAL] 0102.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And can you verify your date of birth, your mailing and email address on file?
[CUSTOMER][NEUTRAL] Yes. My date of birth is [PII].
[CUSTOMER][NEUTRAL] Uh, mailing address [PII].
[CUSTOMER][NEUTRAL] The email address is [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And are these the claims that well, looks like we received some.
[AGENT][NEUTRAL] On [PII] and [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. Um, so let me see what these are.
[CUSTOMER][NEUTRAL] So.
[AGENT][NEUTRAL] Hold on one moment, it is the same claim, yes.
[AGENT][NEUTRAL] 4:30.
[AGENT][NEUTRAL] OK, so we received, I'm just trying to get all the information in one spot.
[AGENT][NEUTRAL] Um, the first claim we received was received on [PII], claim number 36089998.
[AGENT][NEUTRAL] This claim was denied as a duplicate um because the
[AGENT][NEUTRAL] Initial claim that this was uh filed under.
[AGENT][NEGATIVE] was denied because um office visits are not covered by the
[AGENT][NEUTRAL] Policy.
[CUSTOMER][NEUTRAL] Right, yeah. So the reason I resubmitted it is because that was not an office visit at all. Um, the information I was submitting for that claim that said it was denied because it was an office visit was an MRI.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So the information I put in there was the MRI order, the MRI, uh, like the receipt for the MRI, and the explanation of benefits. What I think happened is that the explanation of benefits also had other things in there.
[AGENT][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] And they probably just looked at the office visit, but it was for the MRI.
[AGENT][NEUTRAL] Oh, you know what, hold on one second.
[AGENT][NEUTRAL] And that is true. So that's, that's the reason that it gave for the denial, but once I opened it, each one has a different denial reason. So hold on one second.
[AGENT][NEUTRAL] Um, because this, the duplicate is only for [PII], so I only need to look at this. Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Policy provides no benefits for treatment of conditions other than a sickness or injury as defined by the policy. What is being filed? Hold on one second.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I'm just pulling up the documents so I can see what.
[AGENT][NEUTRAL] What came in and what they're looking for? Hold on one second.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I'll do this one first [PII].
[AGENT][NEUTRAL] It's coming up now.
[AGENT][NEUTRAL] So this is for.
[AGENT][NEUTRAL] Do you mind if I place you on just a brief hold? I'm just looking at the, the documents.
[CUSTOMER][POSITIVE] No, no problem.
[AGENT][NEUTRAL] 60. OK, hold on one moment. I don't know ICD.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] What is happening right now?
[AGENT][NEUTRAL] Like, let me pull up another.
[AGENT][NEUTRAL] Thing and wait let me not do this, let me do this one.
[AGENT][NEUTRAL] Cause I'm so confused, why?
[AGENT][NEUTRAL] 261, 261-0102.
[AGENT][NEUTRAL] Alright, let me see the IBFT.
[AGENT][NEUTRAL] To the new one.
[AGENT][NEUTRAL] Where MRI bilateral with and without contrast. OK. So why isn't this?
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Where was it done I guess is the issue?
[AGENT][NEGATIVE] I'm so confused.
[AGENT][NEUTRAL] MRI facility.
[AGENT][NEUTRAL] So why would it not be covered?
[AGENT][NEUTRAL] OK, I'll ask about that one, move on to the next one.
[AGENT][NEUTRAL] 305, I mean, 3605392, 3605392. So that's what's being denied as a duplicate.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Am I putting the right thing in RMRI DH 0035?
[AGENT][NEUTRAL] What? Benes not payable for condition other than sickness or injury?
[AGENT][NEUTRAL] It's an MRI.
[AGENT][NEGATIVE] How do you know if it's, OK, we're not even gonna go there. So that's that.
[AGENT][NEUTRAL] Yeah I can do what they want. So they're gonna have to deal with it, figure it out. I'm gonna take my note, tell her what I tell her, and get over the claims cause I think we're gonna need some more help.
[AGENT][NEUTRAL] Alright, so that's that one and then this, this one is a dupe of that. 3608998.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] [PII] [PII] OG.
[AGENT][NEUTRAL] OK, and then 36089999.
[AGENT][NEUTRAL] The
[AGENT][NEUTRAL] Yea[PII]
[AGENT][NEUTRAL] Need diagnosis.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, hello [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] Alright, thank you so much for holding. I apologize for that wait. Um, so I went through all the claims. So I'm gonna send this first one.
[CUSTOMER][POSITIVE] No problem.
[AGENT][NEUTRAL] So basically, the claim number 3608.
[AGENT][NEUTRAL] I'm sorry, 36053992 is the original claim um that has the data of service [PII] on it. That was denied um because it's saying that it wasn't.
[AGENT][NEUTRAL] The policy only covers sickness or injury, but it's an MRI so I'm gonna send that one back to claims, um, because I looked under like all your benefits and
[AGENT][NEUTRAL] You, you do have um coverage for the MRI facility. It lists several facilities, so I don't.
[AGENT][NEUTRAL] I'm gonna send that one back to them. Um, the other
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Is that one, would you be able to see if that one has all the, the documents? Cause I think the reason I like resubmitted it was because I might have not had all the documents, like the explanation of benefits on that one. I wasn't sure.
[AGENT][NEUTRAL] Um, let me see, did I pull up the original or the second one?
[AGENT][NEUTRAL] Well, it doesn't matter because the 2nd 1 was denied as a dupe of the 1st 1.
[AGENT][NEUTRAL] Yeah, you have everything here. I mean, I see where it says breast MRI bilateral with and without contrast. So I'm, that's why I'm like, well.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I don't understand, so I'm gonna send that one back because it's an MRI you don't know if it was an accident or sickness or, you know, that's what they're, that's an MRI. So, um, I, I don't understand that one. So I'm gonna um reach out to claims for that one for you.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then um the other.
[AGENT][NEUTRAL] Hold on, let me go back.
[AGENT][NEUTRAL] The other 3, well, the other two claims, um, they all came in on the [PII]. Um, these are denied because we need the diagnosis code. So I can give you the dates of service, um, you can submit.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Like if you have doctor's notes with the with the um diagnosis code on it, um, it could be like a discharge paper, itemized bill. This one doesn't have to be like anything particular. It just has to show the diagnosis code.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Diagnosis code, OK. So if I get that, um, how would I
[CUSTOMER][NEUTRAL] Like, do I have to resubmit a claim or do I have to just submit that form for these claim numbers?
[AGENT][NEUTRAL] Well, no, so I'll give you the data service, um, so you can get the diagnosis for that particular day, and then you can, I mean, you can upload it to the online service and we're just having all the issues because of the new launch. But once you, um, you know, upload it, it's gonna look as if you're submitting a new claim, but we'll know that this is the additional information because that's the only, that's all you have on everything's been processed.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][POSITIVE] OK, perfect.
[CUSTOMER][NEUTRAL] Right, OK.
[AGENT][NEUTRAL] OK, so the first one is [PII].
[AGENT][NEUTRAL] It's this particular claim is from American Home Care Equipment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And let me see what that next one was.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] Um, same place, American Home Care, but it's [PII].
[CUSTOMER][NEUTRAL] Should be from the same.
[CUSTOMER][NEUTRAL] [PII]. OK.
[CUSTOMER][NEUTRAL] So then I just need something from the doctor, like some note from the doctor with the diagnosis code.
[AGENT][NEUTRAL] Mhm. It could be a bill, it could be the um office notes.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] Discharge some. Wait a minute. Hold on one second, let me look at these.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] One, because I just noticed it said and or diagnostic testing results and you have the MRI here. This a different data service. Yeah, OK, never mind, it's a different data service.
[CUSTOMER][NEUTRAL] It is, yeah, because they're for different conditions. Yeah, yeah, they're for different conditions.
[AGENT][NEGATIVE] I'm like, you may be able to use this, but no.
[AGENT][NEUTRAL] And then as soon as we receive it, we'll just go ahead and continue processing and um give you the new decision.
[CUSTOMER][POSITIVE] OK, perfect.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You're welcome. Was there anything else I can help you with today?
[CUSTOMER][NEUTRAL] No, that's all.
[AGENT][POSITIVE] Alright, well, thank you so much for calling APL. I hope you have a good day.
[CUSTOMER][POSITIVE] Thank you you too.
[AGENT][POSITIVE] Thank you. Bye-bye.