AccountId: 011433970860
ContactId: a2b54795-9da0-4cb9-bd78-02689bef2907
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 608650 ms
Total Talk Time (AGENT): 222867 ms
Total Talk Time (CUSTOMER): 194563 ms
Interruptions: 1
Overall Sentiment: AGENT=0.4, CUSTOMER=-0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/09/a2b54795-9da0-4cb9-bd78-02689bef2907_20250409T14:08_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hello [PII], my name is [PII], and I, I got a question on a claim that I put in, uh, just.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, the escort you want the claim number?
[AGENT][NEUTRAL] Yeah, we can work with the claim number. What's that?
[CUSTOMER][NEUTRAL] 358-624-0.
[AGENT][NEUTRAL] OK, give me just one moment, let me pull this up here.
[AGENT][NEUTRAL] All right. And then um on the policy, can I just verify please your date of birth and address?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Like
[AGENT][POSITIVE] All right, thank you so much.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so I've got this pulled up here and I see the denials. There's a couple different.
[AGENT][NEUTRAL] Reasons here what kind of questions did you have?
[CUSTOMER][NEUTRAL] Basically, basically, uh, I had a colonoscopy and that's why I sent in and it doesn't say anything on the claim denial about the colonoscopy, it's about anesthesia and other stuff and.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] I know the colonoscopy is covered, but I don't understand why they didn't acknowledge it.
[CUSTOMER][NEUTRAL] In a description or getting paid for the colonoscopy.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] It's like they, they picked things off of the.
[CUSTOMER][NEUTRAL] The, the, you know, the EOB or whatever I sent, uh, over the explanation benefits and, uh, I don't know, the colonoscopy was the whole reason.
[CUSTOMER][NEUTRAL] It seems like they don't have that on there.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] I don't know if it is a covered test because it says.
[AGENT][NEUTRAL] Medical test for the state of service is not covered.
[AGENT][NEUTRAL] Um, cover tests include MRI, CAT scan, thyroid.
[AGENT][NEUTRAL] With a bunch of other like sleep study, nuclear stress test.
[AGENT][NEUTRAL] See.
[CUSTOMER][NEUTRAL] But I, I had it on a list from our
[CUSTOMER][NEUTRAL] Our to write people that uh.
[CUSTOMER][NEUTRAL] It was on one of the covered, you know, it was covered under there. I mean I didn't go look in the.
[CUSTOMER][NEUTRAL] The Bible that they have for all the parts, but uh they told me it was covered.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let
[AGENT][NEUTRAL] Let me, I'm pulling up the policy to see what I can see in here.
[CUSTOMER][NEUTRAL] And even if it's, uh, I guess even if it's not a.
[CUSTOMER][NEUTRAL] You know, it shouldn't be a a patient procedure or.
[CUSTOMER][NEUTRAL] Surgery or uh.
[CUSTOMER][NEUTRAL] Seem like it
[CUSTOMER][NEUTRAL] Somehow
[CUSTOMER][NEUTRAL] They told me it was covered and
[CUSTOMER][NEUTRAL] Even surgery in the doctor's office is covered.
[AGENT][NEUTRAL] I'm not sure if they.
[AGENT][NEUTRAL] Based off of the procedures.
[CUSTOMER][NEUTRAL] And I don't know for sure.
[AGENT][NEUTRAL] If it would be considered like a surgery.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I don't know that for some reason would it come under.
[CUSTOMER][NEUTRAL] The cancer policy instead of the hospital to
[CUSTOMER][NEUTRAL] Uh, I'm, I'm not sure.
[CUSTOMER][NEGATIVE] All that I seem to have seem to have problems when I file sometimes.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So the way it comes through on the coding.
[AGENT][NEUTRAL] For the procedure codes, it's as a medical testing.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And when you look at the policy, uh, the medical testing that's listed.
[AGENT][NEUTRAL] Um, is like the MRI, CAT scan, PET scan, things of that nature.
[AGENT][NEUTRAL] Um, and then it does include some like follow-up tests.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Like a nuclear stress test, sleep study.
[AGENT][NEUTRAL] But there is not anything in there.
[AGENT][NEUTRAL] It speaks to a colonoscopy that I see.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] I can check. Let me check your other policy and see what's on that.
[CUSTOMER][NEGATIVE] And it really doesn't make sense why that would be excluded, uh.
[CUSTOMER][NEUTRAL] I don't know, that's
[CUSTOMER][NEUTRAL] More than some of the other ones.
[AGENT][NEUTRAL] Sometimes the cancer ones will pay.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] For like a wellness or type of screening like.
[AGENT][NEUTRAL] On there, so there may be a benefit on this one. Let me, I'm checking to see here.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so your cancer policy does list colonoscopy under diagnostic testing. That's number 8 on the list and it does say on this.
[AGENT][NEUTRAL] Where did it go?
[AGENT][NEUTRAL] Um, it looks like $100 and it's a maximum of 1 per calendar year.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So that is on there.
[CUSTOMER][NEUTRAL] So I don't know what do I need to do or can you?
[CUSTOMER][NEUTRAL] Follow up with them and can you get them to
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] What
[AGENT][POSITIVE] Yeah, what I can do.
[CUSTOMER][NEUTRAL] To be specific as to why it's not covered or?
[AGENT][POSITIVE] Yeah, what I can do on this one, [PII], if you're right with it, is I can
[CUSTOMER][NEUTRAL] It's a lot more, it's a lot more invasive than a uh than a X-ray and an MRI and a.
[CUSTOMER][NEUTRAL] And everything else, so I don't, uh, I don't know if it's coded wrong, you know, those things I can't answer and and don't know enough about, but I know our insurance, uh.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Provider people they're they're the ones uh.
[CUSTOMER][NEUTRAL] I said it was covered. I, I don't know what the dollar amount is, and I don't know what specific it needs to go under, but.
[CUSTOMER][NEUTRAL] Seems like it should be covered under under one of the 21 of the reasons we have the policy.
[AGENT][NEUTRAL] Right, right. Um, so what I can do is if you'd like, I can send a request to have somebody in claims call you and they actually um can go over exactly why it was, you know, cause they're the ones processing these. It does have a denial on here. I don't know if you saw that saying no diagnosis code provided.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So, but that.
[CUSTOMER][NEUTRAL] No, that's where they have codes on the thing I sent so I don't, I don't, I don't know what what else they need. So it says code on there with the charges and everything, and, and it says on there HC colonoscopy high risk got a code number it's got a date. It's got everything so.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] I thought I had it covered, but apparently I didn't somehow.
[AGENT][NEUTRAL] Um, is this number you're calling from a good callback number? The [PII]?
[CUSTOMER][NEUTRAL] Uh, no, it probably be better to be my, uh, probably be better to be my cell number. It's uh.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Just to confirm, that was [PII]. Is that correct?
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] OK. Um, I will give them the claim number and just let them know that you would like to know um why it's not covered and what else is needed to get it processed and, um, tell them to give you a call back just, uh, it'll probably be in the next like 24 hours.
[CUSTOMER][POSITIVE] OK, that'd be great. I appreciate your help thank you sir alright bye bye.
[AGENT][POSITIVE] OK. All right. You're welcome. Uh, have a good day.