AccountId: 011433970860
ContactId: 9d54825e-a9be-42f5-8976-da294b48462d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 610820 ms
Total Talk Time (AGENT): 349534 ms
Total Talk Time (CUSTOMER): 213861 ms
Interruptions: 3
Overall Sentiment: AGENT=0.6, CUSTOMER=2.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/17/9d54825e-a9be-42f5-8976-da294b48462d_20250117T16:57_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How can I help you?
[CUSTOMER][NEUTRAL] Hey, [PII]. This is [PII] with the care team. How are you doing today?
[AGENT][POSITIVE] I'm doing well, [PII] thank you how are you?
[CUSTOMER][POSITIVE] Hey, I'm wonderful, thank you for asking. I've got a broker on the line who is calling for a claim status.
[CUSTOMER][NEUTRAL] Um, his name is [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And I have his callback number listed as [PII].
[CUSTOMER][NEUTRAL] He is calling in regards of policy number 2446222.
[CUSTOMER][NEUTRAL] For Miss [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I verified him on the broker page and he was able to verify [PII]'s first last name and date of birth. He's calling particularly for claim number 3552663, and he is curious about what other I did read the remarks, what other medical records are being asked for and needed.
[AGENT][NEUTRAL] And that's the [PII] you're saying? I'm sorry.
[CUSTOMER][NEUTRAL] Mhm. Yes, it is.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And you said you verified them on the broker's side and on the patient side, correct?
[CUSTOMER][POSITIVE] Correct, yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, you can go ahead and put him through. I'm gonna pull up that.
[AGENT][NEUTRAL] Claim information and see if I can figure out what it is we're needing.
[CUSTOMER][POSITIVE] OK perfect and I'll introduce you Ms. [PII] when we join if that's OK.
[AGENT][NEUTRAL] Certainly.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Hi [PII], are you still there with us?
[CUSTOMER][POSITIVE] Yes. Hey there. I have Ms. [PII] on the line. She's excellent. She's one of our examiners and she's gonna be taking a look at that claim and seeing if she can help you identify exactly what else is needed, OK?
[CUSTOMER][POSITIVE] OK, thank you. Hey, my pleasure. Thank you.
[AGENT][POSITIVE] Thank you [PII] have a great day.
[AGENT][NEUTRAL] Hi Mr. [PII], this is [PII] in the claims department. So I'm looking at the um information that was sent and how are you today?
[CUSTOMER][NEUTRAL] Hey [PII].
[CUSTOMER][POSITIVE] Doing great, doing great.
[AGENT][POSITIVE] OK, thank you, that's good to hear, it's Friday so.
[CUSTOMER][POSITIVE] That's right.
[AGENT][NEUTRAL] OK,
[CUSTOMER][NEUTRAL] And normally what I try to do is I try to not even upload them until they have all their information because I don't wanna waste your guys' time. I know how busy y'all are and we're in charge of so many groups that we try not to just upload just anything so I normally me or [PII] will scan it and make sure it's clean before we upload it so we did a claim form.
[CUSTOMER][NEUTRAL] I uploaded an itemized bill that shows
[CUSTOMER][NEUTRAL] It shows the visit charge, it shows X-ray of knee, X-ray of lower leg, um, and then if you go to the one that says Vines diagnosis attachment, this is our after-charge summary that they get from the hospitals here normally. And it'll say, um, diagnosis pain on left calf, left knee pain. Um, let's see, scroll down, it says imaging of the, of knee and of tibia.
[CUSTOMER][NEUTRAL] And let's see, let's see what else it has on here.
[AGENT][NEUTRAL] That's what I'm looking at now, yeah.
[CUSTOMER][NEUTRAL] OK, that's all this particular pages on it.
[CUSTOMER][NEUTRAL] So normally what I try to get you guys is either a UB 04 or an itemized copy of the bill that proves X-rays were taken and they went to the ER and some type of summary that shows why they were there.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] And I think I see what's going on so just bear with me for one moment my system's a little slow. I'm looking at that mail now that was submitted with the claim form.
[AGENT][NEUTRAL] Uh, and it looks like we requested some medical records and
[AGENT][NEUTRAL] Bear with me for just one moment.
[AGENT][NEUTRAL] So we faxed over that request to the Kemp um Kemp Medical Center and.
[AGENT][NEUTRAL] So let's see, so 221 tripped and fell injured knee. OK. So it looks like what we're needing is that accidental uh bodily injury diagnosis.
[AGENT][NEUTRAL] And because the claim um it contained that aftercare summary and also the fact that she did have some uh X-rays taken, uh, we're looking for that accidental bodily injury diagnosis. So uh it, it I believe that we reached out for those medical records to just try to verify that it was in fact due to an accident. So sometimes that
[AGENT][NEGATIVE] Aftercare summary doesn't tell us, they tell us why they were seeing and it looks like it says, you know, pain, uh, let me just go back to that page. My apologies, my system's slower than.
[AGENT][NEUTRAL] I can talk
[CUSTOMER][NEUTRAL] Sure, sure.
[AGENT][NEUTRAL] Um, I just wanna make sure I'm seeing everything. OK, so on that after visit summary, it does say she went to the emergency department. It does say leg pain, but there's nothing to indicate that it was an accident. So a lot of times what we'll do is we'll reach out and ask for medical records cause we wanna try to be able to verify that it was, in fact, the treatment was due to that accident or that accidental bodily injury.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Now, the pain diagnosis, unfortunately, um, and then it shows a couple other, the reason for the visit leg pain and it says hypertension, pain in the left calf, and then left knee pain. So we reached out for medical records to try, try to get some documentation that can verify to us that it was in fact uh an accidental bodily injury. And what that means is that bodily injury can't be like pain or just um
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And like in this case, pain in the left calf or leg pain, we need something to indicate that.
[AGENT][NEUTRAL] Uh, she indicates she tripped and fell into, you know, and, uh, injured her knee, but that bodily injury diagnosis needs to be met under these accident policies. And what that means it has to be independent from any disease or um prior uh diagnosis or, you know, the diagnosis being pain. It needs to be like a sprain, a strain.
[AGENT][NEUTRAL] Uh, a fracture or a contusion, something of that nature that does, like I said, indicate to us that it was a bodily injury. So, like I said, that pain doesn't meet that threshold for that, um, that claim to be eligible as an accident.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm, mhm.
[CUSTOMER][NEUTRAL] Yeah, I feel like
[CUSTOMER][NEUTRAL] Right. I feel like a lot of these doctors, a lot of times don't put the correct diagnosis on here and we have to go chase them down for them to, maybe they're rushing, maybe they're doing whatever they're doing, but if, if she stated she fell and she went in there with knee pain, they should have put that on the, on the, on this form, either accident diagnosis codes or put that under there. But I find a lot of these people are just winging it nowadays and they're just rushing through it, and they aren't putting the right diagnosis codes where we have to turn around and go chase down them to get them to correct their paperwork.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Right. And unfortunately, yeah. Now, sometimes um that if we get that uh X-ray report, which um you know, they'll include that information on that X-ray report or it could also be that um possibly this aftercare summary just has the leg pain, but when they actually sent the claim.
[CUSTOMER][NEUTRAL] And it's probably what is happening in this situation.
[AGENT][NEUTRAL] To insurance they use a different diagnosis, but that's not indicated on the billing statement. They don't give us that diagnosis code which like I said, it prompted us to reach out and ask for that information just like I said so that we can verify that it does meet that eligibility requirement for that exponential bodily injury.
[CUSTOMER][NEUTRAL] Mhm, mhm, mhm.
[CUSTOMER][NEUTRAL] Was this was this information also sent to the insured to try to get it as well?
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] To the claimant
[CUSTOMER][NEUTRAL] Cause a lot of times the employees don't always know what else is needed.
[AGENT][NEUTRAL] Right, let me see what I can find in here.
[CUSTOMER][NEUTRAL] Cause I know a lot of times it's a lot quicker for an employee that they go run up to the doctor then some of these doctor's officers take their time responding on uh on medical records.
[AGENT][NEUTRAL] Of course, yes, but we did contact the facility and got their fax number so we were able to fax it right over um to them looks like we.
[AGENT][NEUTRAL] Spoke to [PII] and medical records and requested the medical records. um, now on [PII] um.
[AGENT][NEUTRAL] Looks like the insured did call us for a claim, uh, claim status, and she was told it was still in process. So then it was processed uh on that [PII] day and the medical records were requested. I don't see that, uh.
[AGENT][NEUTRAL] Let me just double check something. I don't say that we reached out to the insured, um, and as long as they provide that, um.
[AGENT][NEUTRAL] That authorization page, you know, with their claim form, you know, that's why we ask for that so that we can um.
[AGENT][NEUTRAL] We can go ahead and reach out and ask for that information um based on like I said because we're trying to get that um that information to verify eligibility um.
[CUSTOMER][NEUTRAL] Mhm mhm.
[AGENT][NEUTRAL] But I do show it's just pending for that medical record request so it doesn't look like the um it doesn't look like they were uh the insured was contacted.
[CUSTOMER][NEUTRAL] OK, what's the name of the facility? Because I'll have her reach out as well, tell them to respond as quickly as they can.
[AGENT][NEUTRAL] It
[AGENT][NEUTRAL] It's Lally, L A L L I E Lally Camp Regional Medical Center.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And it was for that data service of [PII].
[CUSTOMER][NEUTRAL] All right. I will
[CUSTOMER][POSITIVE] You got it. I'll reach out and I'll uh I'll see if we can get it expedited a little faster.
[AGENT][NEUTRAL] OK, great. Did you have any other questions, Mr. [PII]?
[CUSTOMER][POSITIVE] That's it. I appreciate your time.
[AGENT][POSITIVE] You're so welcome and thank you for calling APL and I hope you have a great rest of your day and a great weekend.
[CUSTOMER][POSITIVE] You too. Thank you.
[AGENT][POSITIVE] Thank you bye bye.
[CUSTOMER][POSITIVE] Thanks bye bye.