AccountId: 011433970860
ContactId: 9e743e5e-b007-4bd2-be2c-cb6cce0996d2
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 696679 ms
Total Talk Time (AGENT): 463590 ms
Total Talk Time (CUSTOMER): 282121 ms
Interruptions: 11
Overall Sentiment: AGENT=1.4, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/20/9e743e5e-b007-4bd2-be2c-cb6cce0996d2_20250320T21:13_UTC.wav
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[AGENT][POSITIVE] Thank you for contacting ATL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], how are you? This is.
[AGENT][POSITIVE] Yes hi how are you?
[CUSTOMER][POSITIVE] Hey, I'm good and you?
[AGENT][NEUTRAL] Oh, I'm still here.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] Um, I have, uh, um, OK, I have a kind of like a weird situation, but I need your help.
[CUSTOMER][NEUTRAL] Um, I have a policy number 1659449.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK, I have Mr. [PII] on the line. He is with the representative of Aetna on the line as well. Um, and they are, um, calling because he spoke to [PII] this morning and it looks like um he has a lot of claims that he needs to send in diagnosis cos.
[CUSTOMER][NEUTRAL] Um, they are, yeah, they are all claims, and he said that um it's about 20 claims that he will have to go to each provider and get that, and he don't think he's gonna be able to get all that. And that says that they don't have that information on the ELBs, but they do have the information verbally that they can give it to him and he can send it to us. I told him that, you know, right now we don't take those over the phone. We don't take it right in either. It has to be like an itemized with the diagnosis code in order for us to process.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] And but he said that since they're all claims that it's gonna be almost impossible for him to get all of them. So I don't know if you can do anything for him. I said, well, let me just, you know, call cu uh claims department and see what we can do, and you know.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Yeah, of course.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] So here's the, so, um, these were, these were processed. I'm just going by them one by one, OK, so these were processed by, by [PII], uh, um.
[CUSTOMER][NEUTRAL] Mhm mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And, um, you know, I guess he can make an appeal, uh, to, you know, he can send in an appeal and ask to have this reviewed if he wants to, but she's the one who did every single one of these. And, um, since she is not only, uh, you know, she's an auditor and she and uh my guess now there, uh, I just got through having one, just, I just got off the phone with her about 3 seconds ago, uh, where we had some going back to 22, 23 where she uh talked to um.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I wouldn't tell this guy that, but where she talked to uh [PII] and and tried to see if, you know, going back to 22, 23, if something like this could be.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So what I would suggest to him is that um and and she actually uh I'm, I'm going to have to go back in and reprocess some that I pinned it for this uh DM 400 because she got these approved on this one guy. So what I would do, um, is that I would have this guy uh reference these uh these claims.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] And uh we can give him the claim numbers we can give him a couple of them just whatever and I'd have him send in an appeal and he can do that. His, his policy is active and he should be able to do that online. In fact, I think he's sending his stuff online. It's now you said he's, uh, he's with a provider or you talking to us.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] No, he, he's, he's with the primary insurance. He's with Aetna, which, um, yeah, like I told him that you usually he, he don't get that information from Aetna, he gets that information from the provider of service, but, um, yeah, I don't know if, if you can just, since I told him I was gonna transfer him, if you can just kind of tell him what to do.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] Yes, of course.
[CUSTOMER][NEUTRAL] And what to send, um, and, um, yeah, so he has like an idea of what to do because, um, and then for future, I just go ahead, um, so you think for future that will be something that we can say that they can just go ahead and send in a meal or no, no, no, no, no, OK.
[AGENT][NEUTRAL] Uh, no, no, no, I really don't. I, the only thing, the only reason that um that uh I'm even suggesting this is the only reason that [PII] called me about them is because the claims were like from [PII], um, and so they were old enough, uh, that we, you know, and so, um.
[CUSTOMER][NEUTRAL] Mm, mhm.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I think that's so what I'm gonna do is I'm gonna ask, I'm not gonna tell him any of that stuff because it's just gonna be confusing. So what I can, I will just ask that uh um.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEGATIVE] That he's sending an appeal on the claims, and I think at this point somebody needs to actually look at them and, and we need to get a directive because we don't want to have to ask this guy back for the money because that's the stuff going through audit and you know that they changed the audit process but now it's just like it's, I don't know, it's like a maze to get through, you know, so we're all very scared audit.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I know.
[AGENT][NEUTRAL] Uh, yes, I will gladly talk to him now. What is his name? I'm sorry, I didn't catch his name.
[CUSTOMER][NEUTRAL] I know.
[CUSTOMER][NEUTRAL] OK. His name is [PII].
[AGENT][NEUTRAL] OK, so you're talking to the to the guy. OK, you're talking to Mr. [PII]. OK, that's.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, I got Mr. [PII] and I got Miss [PII] from [PII]. They're both in the line.
[AGENT][NEUTRAL] OK, and I'm sorry, I, I hate to ask, um,
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I don't speak Spanish at all. I, I, I quit the. Oh, thank you. Thank you, thank you, thank you. I, I took it in high school and that was so many years ago. I'm not even saying, you know.
[CUSTOMER][NEUTRAL] Oh, he speaks English. It's all English.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Trust me, if he was in Spanish, I would have been like, OK, tell me what to tell him.
[AGENT][POSITIVE] Yeah, I think [PII] was in, in, in office when I, when I went was taking Spanish, so yes, thank you very much. I will gladly help him.
[CUSTOMER][NEUTRAL] Oh yeah, you're welcome. All right. Well, here he comes and um the callback number, I'm just gonna go ahead and put it in the system, OK?
[AGENT][POSITIVE] Yes, yeah, I see it ending in [PII]. That's great. Perfect.
[CUSTOMER][NEUTRAL] Um, oh yeah.
[CUSTOMER][POSITIVE] Yeah, OK. All right. Here he comes. Thank you, [PII].
[AGENT][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] Have a good afternoon. You're welcome.
[CUSTOMER][POSITIVE] Thank you for holding and being patient for Mr. [PII]. and Ms. [PII], I got Miss [PII] on the line. Uh, she's in the claims department and she's gonna assist you from here.
[CUSTOMER][POSITIVE] Sure thank you appreciate it. You're welcome.
[AGENT][NEUTRAL] Good afternoon. Thank you for contacting us. Um, I, I have, uh, spoken with, uh, with, with one of my supervisors regarding this, and what we, we just, uh, changed our directives, um, where we were asking for, um, supporting documentation to evidence the uh the uh diagnosis. However, some of your claims date back to [PII], that, that sort of thing, and uh recognizing that that is kind of difficult to get back to you, we were, um, what we were asking.
[CUSTOMER][NEUTRAL] I know
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] Is that you could send a couple you can actually do this online. We do have an online processing service um at [PII] or you can fax it to us and we're asking, sir, if you, uh Mr. [PII], if you wouldn't mind, uh, requesting a review of because at this point what we're doing is we're having our legal department.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Uh, determine what, um, uh, because they, they were actually stating that we needed to get documentation, uh, for the for the DX codes rather than just having someone write it in, but, but we are looking at each.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] And my, my thing is I have, I have access, but my thing is I have access to the you'll be through, through [PII]. I can just, you know, obviously PDF and send it to you guys.
[AGENT][NEUTRAL] Yes, sir.
[CUSTOMER][NEUTRAL] But the diagnostic code, I cannot get from them. I, I cannot get it from anybody other than the doctor. So I would have to go back 3.5 years to each doctor that knows where they are now and kind of say, oh, do me a favor, you know, this is what it is. They're not, they're not just all mine. They're my daughters and my wife's as well, so I don't know how HIPA plays in there.
[AGENT][NEUTRAL] Yes, sir.
[CUSTOMER][NEUTRAL] So, you guys would definitely need some type of paperwork that from the doctor saying,
[CUSTOMER][NEUTRAL] Just a diagnostic code.
[AGENT][NEUTRAL] Well, in future, in future, sir, yes, uh, usually they walk out papers or, or some sort of super bills, office notes, hospital admission. In, in the future, but for right now for the ones that we have already processed, um, because they are, uh, um, it has been some time that has passed.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It's tender, OK, OK.
[AGENT][NEUTRAL] Uh, we are asking, uh, that, um, that, uh, an appeal be submitted and you can just, you can just write it out. You can just say, well, here are the, here are my claim numbers and I'd be glad to give you, you know, just one or two of the claim numbers, uh, just ask, uh, to have them reviewed for yourself, your wife, uh, your child, um, or children.
[CUSTOMER][NEUTRAL] Right, but um.
[CUSTOMER][NEUTRAL] Try that from here on the here on my fingerprint.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Um, for.
[AGENT][NEUTRAL] And uh under certain circumstances, could we please, uh, you know, review this because it will be, it'll pose a difficulty on me to get this, uh, you know, almost impossible information. And then what we're really looking for, sir, is to have something, we just need to have it approved and um so if we could, if we could do that please, uh, and let me give you one of your, uh, actually if you just put in your policy number, um, and the policy number that you provided to soul, that would be great.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] I need to have it OK um.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] But, um,
[AGENT][NEUTRAL] You know, there are several of your claims. uh I can give you one of the claim numbers if you would like. You don't need to reference all of them, but um.
[CUSTOMER][NEUTRAL] Uh, OK, like, like I, I have all the papers here that were returned to me like they were denied, so I have, I have every single claim number that there is.
[AGENT][NEUTRAL] Have you
[AGENT][POSITIVE] Per perfect. Yeah.
[AGENT][POSITIVE] That's perfect. Yeah, they, they were actually, they're actually pended right now. They're not being denied, but yes, if you don't mind submitting that to us, and then just, just explain that you have tried in good faith to get the the DX numbers and what we're doing is we're going on a case by case basis because I said we just changed our directive about this.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, we were taking handwritten diagnosis codes before, but they they suggested that we don't do that anymore, but, but there are, you know, we are looking at in which it'll be almost impossible to get that information. So if you would, sir, if you would mind, uh, sending that into us and actually labeling it as an appeal that you want these, you want these claims to be reviewed by an appeal, uh, uh, an appeal committee, uh, with the view of letting us.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, or having us accept the diagnosis codes that you have provided and just explain, you know, as you have, uh, uh, very succinctly that this years ago, very difficult.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And is that under like a claim is that under the claim tab or is it under appeal tab or something or?
[AGENT][NEUTRAL] Uh, no, sir, you're just gonna submit it just the way you would any of these other documents, the way that you submitted these others, you're gonna do exactly the same thing. And um just ask that your claims be uh be reviewed, your wife, um, any children that, that, you know, you received before, uh, just have a ask us that, you know, this is this is from some time ago, it's difficult for you to do this. And then what they will do is they will have someone who has more authority than I have to review.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] We cannot indeed accept the the uh the claim. So but that is what we're doing right now with these trying to to go on a case by case basis um because it is, you know, unless it's recent sometimes it's difficult to get those.
[AGENT][NEUTRAL] And there are the diagnosis codes from the provider.
[CUSTOMER][NEUTRAL] Right, OK.
[CUSTOMER][NEUTRAL] Yeah, I'm, I'm in here actually. I'm in here right now on your, on, on the website so I can just, I'm just gonna go ahead and.
[AGENT][NEUTRAL] So
[CUSTOMER][NEUTRAL] Go ahead and do that in a in a in a minute or two.
[AGENT][POSITIVE] Great.
[AGENT][POSITIVE] Yes, yeah, and if, and we, we get these in real time.
[CUSTOMER][NEUTRAL] OK, alright, so I don't have to, I don't have to reference all of the claim numbers.
[AGENT][NEUTRAL] Well, no, I, I mean, I would reference like maybe one of them, yeah, oh no, no, no, no, I mean you just say that the recent claims you can actually just put it, put it that way that could be the verb is the recent claims that.
[CUSTOMER][NEUTRAL] I don't have to reference some of the claim numbers, right?
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] We're pinned DM 400.
[AGENT][NEUTRAL] And you would like them reviewed and, and no, that's um you don't need to uh because you have several here, I mean you have quite a few, so um.
[CUSTOMER][NEUTRAL] I like some reviews and and.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Uh, now, is there anything else at all that I can help you with, sir, um, while we're on the line?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] No, that's, that's, that's about it. Thank you so much and I appreciate you.
[AGENT][POSITIVE] OK, well, thank you very much for contacting ATL so you have a very good day.