AccountId: 011433970860
ContactId: 95fafc03-d3d2-4683-a777-2c795fd6a740
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 550409 ms
Total Talk Time (AGENT): 192859 ms
Total Talk Time (CUSTOMER): 226967 ms
Interruptions: 0
Overall Sentiment: AGENT=0.9, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/21/95fafc03-d3d2-4683-a777-2c795fd6a740_20250421T15:42_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], I think I, I pressed the wrong number. I don't know if you can help me. I have a question regarding one of my claims.
[AGENT][NEUTRAL] OK, is it a claim for yourself?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK. Uh, do you have your policy number by chance?
[CUSTOMER][NEUTRAL] I do, it is.
[CUSTOMER][NEUTRAL] 01975687, M as in Mary, L as in Larry, the number 8.
[AGENT][POSITIVE] OK, thank you so much. And do you, can I get your name and your date of birth, please?
[CUSTOMER][NEUTRAL] Name is [PII] Date of birth [PII].
[AGENT][POSITIVE] OK, thank you so much, Ms. [PII]. And do you have a good callback number in case we're disconnected?
[CUSTOMER][NEUTRAL] Certainly, [PII].
[AGENT][NEUTRAL] OK, just need two other pieces of information. What is your address, please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And then lastly, your email address.
[CUSTOMER][NEUTRAL] Um, my work is [PII] or [PII]. I'm not sure which one you have.
[AGENT][POSITIVE] Uh looks like we've got your work one. OK. And then how can I help you today?
[CUSTOMER][NEGATIVE] Well, I'm so confused, um.
[CUSTOMER][POSITIVE] I had some surgery, but I'm calling in regarding a claim I sent in, and I paid $500 out of pocket before my surgery and my, my first um insurance company paid.
[CUSTOMER][NEUTRAL] Most of it, so usually whatever I pay out of pocket, APL picks it up, but they're denying it, so I just don't know why.
[AGENT][NEUTRAL] OK, uh, what date of service?
[CUSTOMER][NEUTRAL] And that
[CUSTOMER][NEUTRAL] Um, [PII].
[AGENT][NEUTRAL] OK, let me look.
[CUSTOMER][NEUTRAL] I have the confirmation number if you want.
[AGENT][NEUTRAL] OK, what's that?
[CUSTOMER][NEUTRAL] O as in Oscar. S as in Sam. C as in Cat. 96472.
[CUSTOMER][NEUTRAL] Excuse me.
[AGENT][NEUTRAL] I
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK, let's see what we got here.
[AGENT][NEUTRAL] I'm reading what we've got here, so let's see.
[AGENT][NEUTRAL] All right, let me see what we received.
[CUSTOMER][NEUTRAL] I guess it should.
[AGENT][NEUTRAL] Well, it looks like, looks like we need.
[CUSTOMER][NEUTRAL] Go ahead, I should maybe send.
[CUSTOMER][NEUTRAL] Hm.
[AGENT][NEUTRAL] Uh, go ahead, sorry about that.
[CUSTOMER][NEUTRAL] No, I thought I didn't send. I did send, um, proof of my payment of $500 on my credit card. I was wondering if I maybe I didn't send that in, but I did. So my first medical.
[AGENT][NEUTRAL] No, that's not.
[AGENT][NEUTRAL] It looks like we need an itemization. Let me, let me pull up what we received from you. Um, hold on one moment.
[CUSTOMER][NEUTRAL] All right.
[AGENT][NEUTRAL] OK, so we got the we got the explanation of benefits from your primary. Let me see what we got.
[AGENT][NEUTRAL] OK, so it looks like what we need is like we need something that indicates what we see what procedures were done, but what was the diagnosis. So we have to make sure that it's due to a
[AGENT][NEUTRAL] Accident or illness, um.
[AGENT][NEUTRAL] So something, something.
[CUSTOMER][POSITIVE] Excellent, I, I.
[CUSTOMER][NEGATIVE] It was an accident. I broke my arm. I fractured my arm in 3 places, and I needed surgery on my wrist.
[AGENT][NEUTRAL] Right, so that's what we're looking for is we need documentation from the provider that shows.
[AGENT][NEUTRAL] Um, what diagnosis you were seen for?
[CUSTOMER][NEUTRAL] And that doesn't explain it from the doctor's explanation of benefits?
[AGENT][NEUTRAL] No, it, it has no diagnosis.
[CUSTOMER][NEUTRAL] I mean, I, I understand. I'm not, I, I'm not getting that information from my doctor. I mean, when, when they submit the claim to my, to my major medical, the UMR, I'm just getting whatever they're sending to UMR and then sending it to APL. That's all I'm getting. I mean, how am I supposed to get this additional documentation?
[AGENT][NEUTRAL] Well, I would ask if they can provide the claim that they sent to UMR to you. That's what we need. So it's, it's, it's, did you, were you seen in the hospital ER is that correct or hospital outpatient?
[CUSTOMER][NEUTRAL] I went to ER and then I had then I went to an orthopedic surgeon the following day.
[AGENT][NEUTRAL] OK, so yeah, so.
[CUSTOMER][NEUTRAL] And then I had surgery the following week.
[AGENT][NEUTRAL] The claim that they submitted to UMR is what we need because that's gonna show us the diagnosis of what you were seeing for so we can, you know, get this claim paid out.
[CUSTOMER][NEUTRAL] But I sent it to you. What I got from UMR, I sent it to you.
[AGENT][NEUTRAL] UMR that that's an explanation of benefits. It's not an actual claim. It doesn't tell us any diagnosis information. There's no diagnosis listed on here, just simply says services you received and then how it paid.
[AGENT][NEUTRAL] It doesn't tell us the actual diagnosis.
[CUSTOMER][NEUTRAL] OK, so I guess I gotta get that from the doctor?
[AGENT][NEUTRAL] Yes, either the doctor or the hospital. Either one should be able to provide it.
[AGENT][NEUTRAL] Um, I would probably call your doc your hospital though, hospital billing.
[AGENT][NEUTRAL] Um, to see if they can provide that to you. It's, it's, I can tell you the name of what we need. It's called a UB04, so U as in umbrella is in Bravo 04. So basically it's a claim and it shows us the services rendered in the actual diagnosis so we can make the determination is it payable on the plan.
[CUSTOMER][NEUTRAL] Oh my [PII].
[CUSTOMER][NEUTRAL] OK, I just thought that that all you needed was the explanation of benefits that that naturally they submit to my major medical UMR.
[CUSTOMER][NEGATIVE] But they're they're not, they're not sending.
[AGENT][POSITIVE] Yeah, we do need that.
[AGENT][NEUTRAL] Which we have.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] But they paid everything but the $500 deductible and I sent you the information that I paid that out of pocket. That's all I'm asking for is the $500.
[AGENT][NEUTRAL] Right, but we still have to have for our documentation purposes, what the actual diagnosis, like what you were seeing for.
[CUSTOMER][NEUTRAL] But you still
[AGENT][NEGATIVE] And that's not encompassed in a a receipt or the EOB from UMR unfortunately.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Um, I also submit it, but I don't see it in my portal. I have a confirmation of O as in Oscar, S as in Sam, C as in cat, 96473. I submitted that on [PII], but I don't even see that. I think they put it together with the, the other one for some reason. I don't know. I don't even see any files. They don't show any files that I sent.
[AGENT][NEUTRAL] Yeah, it looks like they did. They combined it with
[CUSTOMER][NEGATIVE] This is ridiculous.
[AGENT][NEUTRAL] Um, the other claim that we were just discussing, um, which is again the same thing that we need, we need an actual diagnosis, some documentation of diagnosis of what you're seeing for.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK, so I guess I just get that to from the doctors are where I got my surgery from.
[AGENT][POSITIVE] Correct, yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Do I need to put a whole new claim in then again or just submit that?
[AGENT][NEUTRAL] No, no, you don't have to put in a new claim. We'll be able to reference what we've already received.
[CUSTOMER][NEGATIVE] All right, this is very confusing.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right, well, I'm going to the doctor's tomorrow, so I'll see what kind of information I can get from them.
[AGENT][POSITIVE] OK, if they, if, if there's any confusion there just have if they can give us a call we'll be able to happy to explain it to to them exactly what you need.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All right, all right, thank you for your help I appreciate it.
[AGENT][POSITIVE] OK, thank you for calling APL. I hope you have a good day.
[CUSTOMER][NEUTRAL] You too now bye bye.