AccountId: 011433970860
ContactId: 99852ea5-589b-4db0-90ec-16a1a6b4b27a
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 835719 ms
Total Talk Time (AGENT): 415389 ms
Total Talk Time (CUSTOMER): 336370 ms
Interruptions: 3
Overall Sentiment: AGENT=0.8, CUSTOMER=-0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/04/99852ea5-589b-4db0-90ec-16a1a6b4b27a_20250304T18:20_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Oh yeah, um, uh, OK. Um, I'm calling regarding a claim, um.
[CUSTOMER][NEUTRAL] I've sent all the records in, um.
[CUSTOMER][NEUTRAL] I actually, I sent the, um, I sent an itemized list from uh Massachusetts General Hospital. I sent a list of all the services that each provider provided.
[AGENT][NEUTRAL] Yes, sir.
[CUSTOMER][NEUTRAL] And I'm just wondering what's going on with the um the claim.
[AGENT][NEUTRAL] OK, so you're the insured and you filed a claim with us that you're wanting to check on, is that correct? Yes, sir, I can help you with that and who am I speaking with, please?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] First name [PII]. Last name [PII], [PII]
[AGENT][POSITIVE] Thank you. And Mr. [PII], what is a good callback number for you?
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you. And your policy number, please, Mr. [PII]?
[CUSTOMER][NEUTRAL] 0249.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] 8238.
[AGENT][NEUTRAL] OK, thank you. So if you'll give me just a couple of moments to get all of your information pulled up, I will have to.
[CUSTOMER][NEUTRAL] I have the I have the claim number as well.
[AGENT][NEUTRAL] OK, and I will have to verify several things with you first for security, Mr. [PII] and also any information that is provided would be a verification of benefits and not a guarantee of payment. So first off, if you could please verify your date of birth.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK, and the next piece of information to verify with you, Mr. [PII] would be your mailing address.
[CUSTOMER][NEUTRAL] Yeah, it's [PII].
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] And your zip code?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. The phone number we have for you is the same as the one that you gave me, so that is your best contact number, is that correct?
[CUSTOMER][NEUTRAL] Yeah, ending in [PII] yeah.
[AGENT][NEUTRAL] Yes, sir. And lastly, the last thing to verify is gonna be your email address, please?
[CUSTOMER][NEUTRAL] Yeah, it's [PII].
[AGENT][POSITIVE] OK, thank you very much and what claim number are you calling about?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] 00 there it is.
[AGENT][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] 356-7717
[AGENT][POSITIVE] OK, thank you. So one moment please.
[CUSTOMER][NEGATIVE] Now the issue I'm having is.
[CUSTOMER][NEUTRAL] I sent them all the information I sent in by fax. I even had the hospital send you guys a.
[CUSTOMER][NEUTRAL] copy a copy of my complete medical record which they said was completed on [PII].
[CUSTOMER][NEUTRAL] And I received a letter from APL saying that you have the
[CUSTOMER][NEUTRAL] The claim can't be completed completed because you have the don't have the diagnostic codes.
[CUSTOMER][NEUTRAL] Well, I mean, everything else.
[AGENT][NEUTRAL] Yes, the diagnosis codes. Yes, sir, I can see the remark. This claim was just reviewed on [PII], I'm sorry, 224.
[AGENT][NEUTRAL] And it's the denial remark states in order to complete the processing of your claim, we need itemized statements of services provided listing the diagnosis code or codes.
[CUSTOMER][NEUTRAL] But there's, there's 19 different providers.
[CUSTOMER][NEGATIVE] That I saw in my 7-8 day stay in the hospital, I have to contact 19 different providers.
[AGENT][NEUTRAL] This
[CUSTOMER][NEUTRAL] The hospital is saying that they can't whether I call billing or whether I call medical records. They're saying that they don't have the diagnostic codes, the diagnostic codes, those have to be.
[CUSTOMER][NEUTRAL] The um
[CUSTOMER][NEUTRAL] Be given by the provider, but there's 19 different providers that I saw during that. I can't, I can't contact 19 different providers to try to get each individual code.
[AGENT][NEUTRAL] OK, so in a copy of your medical records, they're saying that there is not a diagnosis code?
[AGENT][NEUTRAL] As to why you were in the hospital?
[CUSTOMER][NEUTRAL] I don't
[CUSTOMER][NEUTRAL] Oh, they just need one code?
[AGENT][NEUTRAL] Well, we need the diagnosis code for the time. This was for a hospital admission. Is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Yes, sir. So yes, we would have to have from Massachusetts General for your hospitalization, was this from [PII] I'm sorry, [PII]?
[CUSTOMER][NEUTRAL] Yeah, like I, I don't.
[AGENT][NEUTRAL] Yes, sir. That's what we're needing. The diagnosis code for why you were in the hospital during that time period.
[CUSTOMER][NEUTRAL] Right, but I don't know where to get those. Everyone I talked to was telling me that they don't.
[CUSTOMER][NEGATIVE] They keep passing the buck and this, this department doesn't, that department does it. I mean, I, I don't know what to do here.
[AGENT][NEUTRAL] OK. Medical records, that should be included in your medical records. Information, Mr. [PII].
[CUSTOMER][NEUTRAL] Right, and those medical records were sent.
[AGENT][NEUTRAL] OK, so do you mind letting me place you on a brief hold?
[CUSTOMER][POSITIVE] Yeah, OK, and there's one more thing, like I had Affleck for over 15 years and I never had any, never had any type of trouble like this.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] I mean the city of Everett signed on to you guys back last summer or whatever when we went through our new um.
[CUSTOMER][NEUTRAL] Uh, whatever they call it, the, um.
[CUSTOMER][NEUTRAL] The period where you uh apply for that.
[AGENT][NEUTRAL] Your open enrollment, like you're opening. Mhm.
[CUSTOMER][NEUTRAL] There you go, yeah.
[CUSTOMER][NEUTRAL] And I, I just, I mean, I've had a, I just don't know. I don't know what else to do.
[AGENT][NEUTRAL] And you have asked the facility for an itemized bill including, that includes your diet?
[CUSTOMER][NEUTRAL] I, I, I called them 4 different, uh.
[CUSTOMER][NEGATIVE] I spoke to 4 different people before I called you today, and it's like this one has it, that one has it, and they keep passing me back and forth. But my entire my entire my entire medical record from that.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] From that hospital stay was sent.
[CUSTOMER][NEGATIVE] From what they're telling me to you guys on on [PII] or whatever it was completed on the [PII], like I, I, I don't know where to get these medical codes.
[CUSTOMER][NEGATIVE] And I've never had to deal with this with any, uh, I, I got colonial my first few years on the job. I had Affleck, and I've never had anything like this happen. This is, this is crazy.
[AGENT][NEUTRAL] So.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So they're saying that they just sent that to us on like.
[AGENT][NEUTRAL] A week or so ago.
[CUSTOMER][NEUTRAL] Yeah, they said the medical records was the, the medical record request that I put in was completed on this, uh, sorry, on [PII].
[AGENT][NEUTRAL] OK, so we haven't received that information yet.
[AGENT][NEUTRAL] If they mailed us medical records on [PII], that information hasn't been received by us yet. We just had that hasn't had enough time to get here with it only being [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] What they
[AGENT][NEUTRAL] That would have been just
[CUSTOMER][NEUTRAL] Yeah, I'm thinking, oh, so they wouldn't fax it, they'd send it.
[AGENT][NEUTRAL] I'm gonna tell you that all we have received was a total of 3 pages on the claim that we, the information that we currently have that was reviewed. That's what we have, yes, sir. So, um,
[CUSTOMER][NEGATIVE] Oh, no, no, no, no.
[CUSTOMER][NEUTRAL] Oh,
[CUSTOMER][NEGATIVE] No, so I have another, you only received 3 total pages?
[AGENT][NEUTRAL] I'm looking at it, it takes a moment to load all this information, but on the one set that I just looked at.
[AGENT][NEUTRAL] Yes, um, it's still loading. So it sounds like we are still waiting for some, then there was a total of 8 pages that included a claim form.
[CUSTOMER][NEUTRAL] Oh, OK, wait a minute.
[CUSTOMER][NEUTRAL] Is that
[CUSTOMER][NEUTRAL] Oh, you did get 8 pages.
[AGENT][NEUTRAL] Mr. [PII]. Uh-huh.
[CUSTOMER][NEUTRAL] OK, so, OK, that's all. Yeah, there's the provider.
[AGENT][NEUTRAL] Yes, sir, but that, this does not have the reason that you were in the hospital.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] This is just
[CUSTOMER][NEUTRAL] There's a profession.
[AGENT][NEUTRAL] Mhm. That's just.
[CUSTOMER][NEUTRAL] Uh, where would I get the reason I was in the hospital?
[AGENT][NEUTRAL] You would get that from the.
[CUSTOMER][NEUTRAL] It was for a blood infection.
[AGENT][NEUTRAL] Yes, sir. The hospital will have that information, so I'm not sure why they're.
[AGENT][NEUTRAL] Telling, uh, I'm, I, I'm so sorry. I can't answer that.
[AGENT][NEUTRAL] But they have to have that information.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Uh, so would it be in the medical records?
[AGENT][POSITIVE] It should be, yes, sir, absolutely.
[CUSTOMER][NEUTRAL] OK, so they don't.
[AGENT][NEGATIVE] Because this is just a hospital charge. This is just charges. This
[AGENT][NEUTRAL] Yes, sir, but it's, I'm looking at each page of what we received.
[AGENT][NEUTRAL] And it shows Medicare, you know, the payments, adjustments, but
[CUSTOMER][NEUTRAL] But you have an itemized list itemized list of uh of each provider?
[AGENT][NEUTRAL] P
[CUSTOMER][NEUTRAL] And then
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] No, so what we have, what you, what we received was from Mass General Brigham.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And it's a
[AGENT][NEUTRAL] Let's see, MGHer Massachusetts General Hospital.
[AGENT][NEUTRAL] And it's for data service 1228.
[CUSTOMER][NEUTRAL] 314.
[AGENT][NEUTRAL] So far, I'm still looking. 1229.
[AGENT][NEUTRAL] Mm 12:30, 31.
[CUSTOMER][NEUTRAL] Uh, so you have the piece of paper that shows the doctors or no?
[AGENT][NEUTRAL] No, sir.
[AGENT][NEUTRAL] We do not have any of that.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK, so you don't have a um.
[CUSTOMER][NEUTRAL] It's actually, well, actually I was probably fax it in two pages where it lists each.
[AGENT][NEUTRAL] Let me look at
[CUSTOMER][NEUTRAL] Proceed to the description and each provider like the first one is [PII].
[CUSTOMER][NEUTRAL] Oh, you don't have that.
[AGENT][NEUTRAL] No, so I don't have that.
[CUSTOMER][NEUTRAL] Oh, so OK, so you just have the 6 pages of.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] But procedure code isn't the same as diagnostic code.
[AGENT][NEUTRAL] Yes, I do have the billing. Yes, we do have the a separate document that has the billing provider's names.
[CUSTOMER][NEGATIVE] All the doctors' names, yes. That's not enough.
[AGENT][NEUTRAL] Yes, sir, but they
[AGENT][NEUTRAL] No, sir, because that still doesn't, that just gives procedure codes out next to their names. It doesn't, that tells what they did, but we need to know the why they did it, which is the diagnosis code.
[CUSTOMER][NEUTRAL] Alright, so in
[AGENT][NEUTRAL] So it sounds like at the hospital said they sent your medical records. Again, we just haven't received those yet.
[CUSTOMER][NEUTRAL] In your experience
[CUSTOMER][NEUTRAL] Yeah, they completed. OK, they completed the request from what they say on, on, uh, [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Oh, yes, sir. So with today only being [PII].
[AGENT][NEUTRAL] We need to give that probably a little more time, especially via mail.
[CUSTOMER][NEUTRAL] OK, OK, but yeah, I, I'm thinking they can mail it.
[AGENT][NEUTRAL] You know,
[AGENT][NEUTRAL] Because that was, OK, so if they completed their your request or their request processed on the [PII] that was on a Friday.
[AGENT][NEUTRAL] So, you know, depending on what time of the day it was, as to whether, you know, that probably even went out.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Monday.
[AGENT][NEUTRAL] Until probably the [PII], which was just last week.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEGATIVE] So, yes, sir, we, we really haven't had time to receive that yet.
[CUSTOMER][NEUTRAL] Yeah, because
[CUSTOMER][NEUTRAL] Monday was the holiday, OK. So, but as far as you know, the, so your experience of dealing with this stuff in the past that the, the, the diagnostic code should be in those medical records?
[AGENT][POSITIVE] Oh and that's right.
[AGENT][NEUTRAL] Well, again, it's the diagnosis, not the diagnostic. The diagnostic is your procedure. I mean, that's more like what they did to you. We need to know why you were there.
[CUSTOMER][NEUTRAL] So, diagnostic and procedure is the same thing?
[AGENT][NEUTRAL] That is
[AGENT][NEUTRAL] No, they're different.
[AGENT][NEUTRAL] diagnosis is the why.
[AGENT][NEUTRAL] What we've received is the what they did to you while you were there.
[AGENT][NEUTRAL] The procedure codes are different than diagnosis.
[CUSTOMER][NEUTRAL] Alright, so the diagnosis code should be in the medical records, right? Uh that's how it works.
[AGENT][NEUTRAL] Yes, sir. Yes, sir. I mean, they should be. Obviously, I can't say for certain, but yes, sir, they.
[AGENT][NEUTRAL] They should be.
[CUSTOMER][NEUTRAL] Alright, so I should wait until you get those, right?
[AGENT][NEUTRAL] Yes sir I would just give it a little bit longer if they indeed said that they did mail them to give them time, you know, I mean to get to us and to be processed and reviewed.
[CUSTOMER][NEUTRAL] Yeah, yeah, OK, so you definitely don't have them right now, OK.
[AGENT][NEUTRAL] No, sir, we haven't because we processed this claim, again, this was processed on the [PII] of, so that was last Monday.
[AGENT][NEGATIVE] Well we denied it saying that we needed that. So, yes, sir, we haven't, we just haven't gotten anything yet.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] Oh, all right, so they should be in OK.
[CUSTOMER][NEUTRAL] but hopefully they're there because if they're not.
[AGENT][NEUTRAL] And I can
[AGENT][NEUTRAL] And 2, you are set up where you should receive a text notification alert, Mr. [PII].
[CUSTOMER][POSITIVE] Yeah, yeah, I have gotten those yeah.
[AGENT][POSITIVE] Once we receive it and process it, yes, sir, you should get that as well.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] But you're also welcome to call back.
[CUSTOMER][POSITIVE] All right, very good, thank you.
[AGENT][POSITIVE] Well, you are certainly very welcome. Is there anything else that I could help you with this afternoon?
[CUSTOMER][NEUTRAL] No, that's it.
[AGENT][POSITIVE] OK, well thank you Mr. [PII] for calling APL and I hope that you have a very nice afternoon.
[CUSTOMER][NEUTRAL] OK, bye.
[AGENT][POSITIVE] Thank you. Bye-bye.