AccountId: 011433970860
ContactId: 955e7c2e-d1fd-400e-bd58-0135dedc2c75
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 820739 ms
Total Talk Time (AGENT): 260368 ms
Total Talk Time (CUSTOMER): 222125 ms
Interruptions: 0
Overall Sentiment: AGENT=0.5, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/27/955e7c2e-d1fd-400e-bd58-0135dedc2c75_20250327T16:51_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Good morning. Uh, this is [PII] calling, and I wonder if you can help me with a claim that I just submitted and got the explanation of benefits, and I'm not sure what else you need on this.
[AGENT][NEUTRAL] OK, sure, I can assist you with claim status. And may I have a callback number just in case we get disconnected, Mr. [PII]?
[CUSTOMER][NEUTRAL] OK, that'd be [PII].
[AGENT][NEUTRAL] OK, thank you. May I have the policy number?
[CUSTOMER][NEUTRAL] The policy is 02013328.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] All right, and for security, may I have the date of birth, mailing address and email address on file?
[CUSTOMER][NEUTRAL] Uh, date of birth is [PII]. Mailing address is [PII], and I think you asked for an email address.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, that'd be [PII].
[AGENT][NEUTRAL] We have a gold pea.
[CUSTOMER][NEUTRAL] No, that one's not in effect any longer.
[AGENT][NEUTRAL] OK, so we need to change that. OK. Let me have the, the one that you just mentioned, so I can change it.
[CUSTOMER][NEUTRAL] OK. Um, [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so you said that you're calling about the most recent claims.
[CUSTOMER][NEUTRAL] Um, and there's a bunch of them, so this is claim number 358-0225.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] OK, bear with me just a second. Let me pull the image on that EV.
[AGENT][NEUTRAL] I'm waiting on the documents.
[CUSTOMER][POSITIVE] No, no worries.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] All right, let's see.
[AGENT][NEUTRAL] OK, that's cool. I need to consider need and documents reporting.
[AGENT][NEUTRAL] Yes 4043.
[AGENT][NEUTRAL] data service.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] Let me see if I got anything else for that data service, OK, one moment.
[AGENT][NEUTRAL] OK, so it looks like what we were asking for is itemized bill for the independent lab. It needs to have the diagnosis code.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] You think you can get that information, Mr. [PII]?
[CUSTOMER][NEUTRAL] Well, uh, I don't have it from the lab, but I sent the diagnosis codes from the, uh, doctor's office visit that prescribed the lab testing.
[AGENT][NEUTRAL] OK, yeah, we cannot use that because that comes from another provider. So basically it has to be the, the lab itself because that's a different facility, um, they use their own codes um.
[AGENT][NEUTRAL] So it
[CUSTOMER][NEUTRAL] So we need an itemized from the code. The lab test is one thing. I'm not so worried about that. What I'm really concerned with is these big facility charges from McLaren Oakland Hospital for this, the chest CT and uh the other stuff that they did, which
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Generally
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] I don't know what else you're gonna need on that.
[AGENT][NEUTRAL] OK, let me pull that date, um, that was [PII] and [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] OK, I might need to get the examiner to look into this because I see that it was um put under.
[AGENT][NEUTRAL] Duplicate charges, but mm I'm trying to locate the original one. Let me check one more time, OK?
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Yeah, I started submitting stuff as I was receiving the bills and the documentation. You kind of kicked them out saying you didn't have, I didn't have the codes. So what I did on this case was just got referred to the first two claims, um, and submitted supplemental information which would have been the itemized bills from the doctor's office for 2 visits that required all these testings.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And I thought that was going to be enough, but I mean the processing just went through and said, yeah, we've seen this before.
[CUSTOMER][NEUTRAL] So I'm not sure if anybody really looked at what I submitted or or just that it was a duplicate.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm mhm I see.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] And this was for [PII] correct?
[CUSTOMER][NEUTRAL] This is for [PII], yes.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Let me see what happened to her original claim. I just see one more here.
[AGENT][NEUTRAL] 356 4.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so the original claim, which it was, um, let me tell you when we receive and process this one.
[AGENT][NEUTRAL] Um, 766. OK, it's the one that was submitted to us on [PII] and we processed on [PII]. That was the original submission, the first submission ever, and on that submission, we requested itemized bill with the diagnosis codes and procedure codes. OK. Um.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] And let me see.
[AGENT][NEUTRAL] What happened then because that is still.
[AGENT][NEUTRAL] They still saying that it's still missing that information, so let me see.
[CUSTOMER][NEUTRAL] Yeah, because the first one I submitted was just for the chest X-ray, and I did not have the diagnosis codes on that, but I think what happened was because there were additional things on the or additional items on the statement from my primary insurance that that got admitted as a claim and then came through when I sent the documentation in for that the next time around he said it was a duplicate.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] So that's why on the 3rd time I tried to just combine everything together and said, OK, here's the whole thing starting with the doctor's visits and the codes associated with that, that's at the lab work, that's at the chest X-ray, that's at the CT and the uh the heart monitor.
[CUSTOMER][NEUTRAL] So this last claim has everything and I just need to know what else we need to be able to get that to process.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Yeah, and I'm looking at the paperwork. I'll probably have to send this to a specialist and have them call you, but um let me see what I can do, OK?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so basically what I see here, and this is just what I see off the back, um.
[AGENT][NEUTRAL] I don't see a diagnosis code.
[AGENT][NEUTRAL] So I, I see the explanation of benefits that you submitted.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] I do see um some bills like direct bills. The direct bills doesn't have any diagnosis codes. Usually, the diagnosis code is asked directly from the provider of service, so you have to call them, ask them to send you a, a fully itemized bill with the diagnosis code and it's a separate, um, it's a separate document from the one they sent.
[CUSTOMER][NEUTRAL] OK, so the, so the ones from the hospital or from the doctor that prescribed it, that doesn't count. You need an itemized bill from, from the hospital.
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Correct, from the hospital. It has to come based on who did the procedure, why they had to do that procedure, what is the diagnosis, um, is it because of pain and um what happened. So basically, um, we're gonna need that information from the doctor that did the procedure.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I will try to track that one down.
[AGENT][NEUTRAL] OK. So the best thing is to call the hospital and have them to send that over to you. Call the hospital, let them know that you need a fully itemized bill with diagnosis codes.
[CUSTOMER][NEUTRAL] Now, when I
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] When I submit that, do I just put in another claim or is there a special way that I should be OK, so just a regular claim, OK.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] Very good then I will see what I can do thank you.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Alright, you're welcome. Is there anything else I may help you with today, Mr. [PII]?
[CUSTOMER][NEUTRAL] No, that, that should do it.
[AGENT][POSITIVE] OK. Well, thank you for calling APL. Have a good day.
[CUSTOMER][POSITIVE] OK thank you bye bye.
[AGENT][POSITIVE] You're welcome. Bye-bye.