AccountId: 011433970860
ContactId: 9e6320fe-1c61-4210-8366-2827698628e8
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 699179 ms
Total Talk Time (AGENT): 492493 ms
Total Talk Time (CUSTOMER): 152523 ms
Interruptions: 5
Overall Sentiment: AGENT=0.1, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/14/9e6320fe-1c61-4210-8366-2827698628e8_20250314T16:23_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], this is [PII] over on the care team. How are you today?
[AGENT][POSITIVE] I'm good how are you [PII]?
[CUSTOMER][NEUTRAL] Doing good thank you. I've got a member on the line uh who was calling regarding an accident claim um I tried to just explaining it looks like we're just missing some information and requested medical records um and she just asked to speak with someone in claims so I think she's just a bit confused.
[AGENT][NEUTRAL] OK, uh, what's the policy number?
[CUSTOMER][NEUTRAL] It is 02545851.
[AGENT][NEUTRAL] OK, let me get over there real quick.
[CUSTOMER][NEUTRAL] Mhm we're speaking with part one, but the claim is for part two.
[AGENT][NEUTRAL] Part two, OK.
[AGENT][NEUTRAL] Is it, uh, 357-1687?
[CUSTOMER][NEUTRAL] Yes, that's it.
[AGENT][NEUTRAL] OK. And
[AGENT][NEUTRAL] Metal recorder
[AGENT][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] I think she's a bit confused because she saw that the status as of today is that it had completed and I tried explaining that just means that it had completed processing and so now we see the information that's needed um that I don't think she quite understands when it says completed.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Got you, OK.
[AGENT][NEUTRAL] So we had.
[AGENT][NEUTRAL] A failed knee replacement? Am I reading that right?
[CUSTOMER][NEUTRAL] She said he fell off the bed and busted his knee.
[AGENT][NEUTRAL] Oh [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEGATIVE] Man, I needed a knee replacement for that. That is awful.
[CUSTOMER][NEUTRAL] OK, how high up is this bed?
[AGENT][NEUTRAL] I'm right. Oh gosh. OK.
[AGENT][NEUTRAL] I'm trying, I'm just trying to look at these records and figure out what.
[AGENT][NEUTRAL] Like
[AGENT][NEUTRAL] What would be requesting for?
[CUSTOMER][NEUTRAL] Sure, yeah, that's where I was, you know, the, the note like I understand, but it is a bit vague. I wish I had something more particular or specific I could give her.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] No, yeah, I understand where you're coming from on this because it's like mm.
[AGENT][NEUTRAL] I mean, we have a diagnosis code.
[AGENT][NEUTRAL] Kind of what else?
[AGENT][NEUTRAL] I guess would be needed.
[AGENT][NEGATIVE] Other mechanic complication, other.
[AGENT][NEUTRAL] Let me just look this up because lying abbreviates it and sometimes I can I know what I'm doing and sometimes I'm like I don't know what that is.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Oh, OK, so.
[AGENT][NEUTRAL] Mm, OK, other mechanical complication of other internal orthopedic device implants and grafts. OK, so there was a complication, which is why I think his.
[AGENT][NEUTRAL] His claim form says that he had a failed.
[AGENT][NEUTRAL] Knee replacement.
[AGENT][NEUTRAL] I think that's why, so.
[AGENT][NEUTRAL] Because there's not really anything on here that indicates.
[CUSTOMER][NEUTRAL] Oh, so we would just need like the supporting evidence of that.
[AGENT][NEUTRAL] Yeah, like, yes, he had a failed knee replacement, but is, is the knee replacement not good because he just had it and he fell and, you know, cause she's saying he fell and busted his knee. So is it.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] The injury, the reason why this failed or is it just because if it's not accident related with with it being an you know an accident policy then.
[CUSTOMER][NEUTRAL] I see. OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The then it's not gonna be, you know what I'm saying? Yeah.
[CUSTOMER][POSITIVE] Right, yes, yes, that makes perfect sense.
[AGENT][NEUTRAL] Plus we don't have her, um.
[AGENT][NEUTRAL] Or his claim form, this is just the attending claim form?
[AGENT][NEUTRAL] Um, that I can see.
[AGENT][NEUTRAL] I mean unless we've received something previously and just hadn't let's see.
[AGENT][NEUTRAL] What is that 1 5473? Let me see what that says. Oh, that's the record request.
[AGENT][NEUTRAL] Oh hang on, there it is.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Because I'm wondering like did she submit something before?
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] What have we paid before?
[AGENT][NEUTRAL] So many components here.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, that's a screening, so that is not gonna matter.
[AGENT][POSITIVE] And that's a screening. OK, so what we've paid so far it's just been a screening so we haven't paid on anything, I guess that's good news.
[AGENT][NEUTRAL] Um, so it's not like we've already paid for this accident and we're trying to see if there's something else. It's really just determining this accident. So let me look at one last thing and then I should be able to kind of explain what's going on here.
[CUSTOMER][NEUTRAL] I see. OK.
[CUSTOMER][NEUTRAL] OK, OK.
[AGENT][NEUTRAL] Uh, why is that doing that?
[AGENT][NEUTRAL] OK
[AGENT][NEGATIVE] Because it looks like we received something previously and we denied that for um.
[AGENT][NEUTRAL] That we needed supporting documentation to evidence the accident and when it occurred, which could be office notes, hospital admission and discharge summaries like all of that.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I did, yeah, I read, I read her that I was just looking in the uh CL REM, um, and I think she, she must have, uh, had some experience with us before because at that point she goes, can I just speak to someone in claims? I was like, OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Bless it.
[AGENT][NEUTRAL] OK, so.
[AGENT][NEUTRAL] What we received previously was essentially something from her primary payer.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] An office visit on [PII] and that's pretty much it.
[AGENT][NEUTRAL] Like there wasn't anything there, there were diagnosis codes, but they weren't accident related until, until we got the claim form from the physician.
[CUSTOMER][NEUTRAL] Right, OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] So he was complaining of pain.
[AGENT][NEUTRAL] In both of his knees, truly pain in left knee, pain in right knee, that was, of course, if he fell, he locked, I mean, I'm assuming he hit both. I don't know. I don't know how this pain, but
[CUSTOMER][NEUTRAL] I don't either.
[AGENT][NEUTRAL] When he went on 23 it says presence of left artificial knee joint. So he already had the artificial joint, it looks like.
[AGENT][NEUTRAL] And then, and now I don't know when that was in there and then this one says.
[AGENT][NEUTRAL] Mechanical complication of like an implant or an orthopedic device.
[CUSTOMER][NEGATIVE] Oh, what a mess.
[AGENT][NEUTRAL] So it could be, yeah, so it could be he already had it. He fell. He went in for pain. Looks like the, something happened to the joint, but that's what the records are for. Uh, and I'm, I can explain that, but yeah, it's just piecing it all together and girl.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I see. OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] No kidding. Yeah, that's a lot. I'm finding those missing pieces. Um, alrighty, well, I sure appreciate your help. Are you ready to talk to her?
[AGENT][NEUTRAL] It's everywhere. I know, I know.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah, I can take her.
[CUSTOMER][POSITIVE] OK alright I will send her over thank you [PII].
[AGENT][POSITIVE] OK, you're welcome.
[CUSTOMER][NEUTRAL] Alright, bye.
[AGENT][NEUTRAL] Bye.
[AGENT][NEUTRAL] Ms. [PII]?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Hey, this is [PII] with the claims department. How are you?
[CUSTOMER][NEUTRAL] Hi [PII], how are you?
[AGENT][NEUTRAL] I'm doing well. um, so [PII] transferred you over. She let me know that you had some questions about um like while we were requesting records, I guess, or why, OK, so I was looking at everything you've submitted for, um, Mr. [PII] so far and it looks like the first thing we received was like an office visit where he was going in complaining about the pain that he was experiencing in early February.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then the next thing we received was the attending physician statement saying that he had a failed knee replacement, um, so.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] What I'm gathering from that information, OK.
[CUSTOMER][NEUTRAL] He fell.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, is that the, and this is not your fault, but.
[AGENT][NEUTRAL] There is no on the um.
[AGENT][NEUTRAL] Attending physician statement, there's not anything that says like that an accident occurred. It just says that his knee replacement failed, you see what I'm saying? And so the records are just to verify the accident and so they went ahead and requested that I'm actually gonna see if there's a note on this claim specifically.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Not that we don't, you know, we're, we don't make assumptions on there we just wanna, you know, make sure we have all of our information and so since they didn't include that on their form because literally it doesn't say failed as in like he fell down, it's failed like FAI LED like it's not working um and so that's kind of vague, you know what I mean like obviously if you've had an, when did he have his knee replacement if you don't mind me asking?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] 3 years ago, 4 years ago.
[AGENT][POSITIVE] Oh [PII] bless him, OK.
[CUSTOMER][NEUTRAL] Yeah, so it's been a long time.
[AGENT][NEUTRAL] Yeah, so really the biggest thing is determining did the fall cause the failure, you know what I'm saying? like because he hit his knee and if so then obviously that's what we're moving forward with, um, but they didn't really explain that on their form they just said, well, his knee replacement's not working anymore you know what I'm saying?
[CUSTOMER][NEUTRAL] So I
[CUSTOMER][NEUTRAL] So yeah, so y'all need to get the the.
[CUSTOMER][NEUTRAL] So y'all need to get the medical records.
[AGENT][NEUTRAL] Mhm. Yes, ma'am. So, let me see if she, I believe she did actually. Um, I'm gonna confirm that actually. So yes, she did request medical records that was sent out uh last Wednesday.
[CUSTOMER][NEUTRAL] Did y'all request them?
[AGENT][NEUTRAL] So it's been about a week so we have requested those we're just waiting on them to respond. Sometimes there's a quick response, it may take a week or two. I don't see that we've gotten it yet. Sometimes it could take 30 days. I really hope it doesn't take that long, um, but it could. The only way to get that faster would be if you had access to the medical records through like a an online portal with the facility or with a doctor, OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] No, I don't, but I can, I can call him now.
[AGENT][NEUTRAL] OK, um, because sometimes they'll they'll give us.
[CUSTOMER][NEUTRAL] OK. When I saw it completed, I was just like, what?
[AGENT][NEUTRAL] Yeah yeah um it's, it's not completed as in you're not getting anything it's completed in that we've reviewed it and we just need some more and we've made that request on your behalf.
[CUSTOMER][POSITIVE] OK, thank you so much I'll see if I can get him. OK, thank you bye bye.
[AGENT][POSITIVE] Yes, ma'am, of course. OK. You're welcome. Bye-bye.