AccountId: 011433970860
ContactId: a7a0a575-c8e4-46a1-8bf1-5b6b5724ae20
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 711109 ms
Total Talk Time (AGENT): 249462 ms
Total Talk Time (CUSTOMER): 266593 ms
Interruptions: 5
Overall Sentiment: AGENT=0.7, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/16/a7a0a575-c8e4-46a1-8bf1-5b6b5724ae20_20250616T20:08_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII] calling, and I got a, I received a letter last week, um, from ATL regarding a claim. Our son, um, was in the ER.
[CUSTOMER][NEUTRAL] And um I've been emailing and sending information and the letter just says we've received the claim the review has started it's the same letter I got back in April, so I just wonder what more information I need if I can figure out that I need to provide to move things forward.
[AGENT][NEUTRAL] OK, I can check and see. Um, do you have a callback number just in case we get disconnected and the uh account number, the policy number?
[CUSTOMER][NEUTRAL] Yes, um, um, my phone number is [PII].
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I'm looking.
[CUSTOMER][NEUTRAL] Would it be
[CUSTOMER][NEUTRAL] Would it be the member number or something else?
[AGENT][NEUTRAL] And the policy certificate.
[CUSTOMER][NEUTRAL] And that's on my card?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh oh, I have a policy number here. I'm sorry. It's 02.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] 599625
[AGENT][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK. For security, may I have your date of birth, mailing address and email address on file?
[CUSTOMER][NEUTRAL] Yeah, um, date of birth is [PII].
[CUSTOMER][NEUTRAL] And the address you said?
[AGENT][NEUTRAL] Mailing address and email address. Mhm.
[CUSTOMER][NEUTRAL] Is that right?
[CUSTOMER][NEUTRAL] Yeah, mailing address is [PII] and my email is [PII].
[AGENT][POSITIVE] Perfect thank you. Alright, let's see where we are with the claim.
[AGENT][NEUTRAL] And this is for the plan.
[CUSTOMER][NEUTRAL] [PII], mhm, yeah.
[AGENT][NEUTRAL] No, OK, um.
[AGENT][NEUTRAL] OK, so it looks like it was a resubmission. Let me look at the
[AGENT][NEUTRAL] Original claim and see what happened there.
[CUSTOMER][POSITIVE] OK, guys, thank you so much. That would, uh, yeah, [PII].
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] I, um,
[AGENT][NEUTRAL] Right, um.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Just a second, let me pull the two claims and see what's the difference.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] I see.
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] I.
[AGENT][NEUTRAL] OK, so it looks like on the first uh submission um we denied stating that we needed an itemized bill with diagnosis codes.
[AGENT][NEUTRAL] And then on the second submission, go ahead.
[CUSTOMER][NEUTRAL] Right, right, so I called.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] Oh, I was just gonna say you're right, and so that's what I was told, so I had to call Cleveland Clinic and then I did put all the codes and um that they gave me, they would only do it over the phone.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] And I wrote it and scanned it.
[CUSTOMER][NEUTRAL] Back to uh claims.
[CUSTOMER][NEUTRAL] And then received this recent letter so I just don't know what happened after they received that information.
[AGENT][NEUTRAL] Mm, um, what page did you write those in? Um, was it like in the form?
[CUSTOMER][NEUTRAL] Um, yeah, I used the bill that Cleveland Clinic sent me and the itemized bill and then wrote the code that they gave me over the phone, um, next to each one and then the additional ones because there were so many different codes for chemistry and hematology.
[CUSTOMER][NEUTRAL] Um, microbiology, and there's like 6 codes for that lab urology, his histology, CPT had one and they gave me the cost, but I don't know. That's what I sent back with the itemized bill that they had sent to me.
[CUSTOMER][NEUTRAL] Um, for his treatment and then I wrote the codes, like I said next to what I could and then the additional code she gave me which I didn't know where they fit in on the bill.
[CUSTOMER][NEUTRAL] Which I attached to the bill.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] OK, um, let me check something, and I'm just pulling all the documents that are in both of the claims to see.
[AGENT][NEUTRAL] What happened, um, you're welcome.
[CUSTOMER][POSITIVE] Oh great thank you.
[AGENT][NEUTRAL] OK, these are CPT codes, uh, let's see.
[AGENT][NEUTRAL] Yeah, we're looking for a diagnosis code.
[AGENT][NEUTRAL] Not CBT.
[CUSTOMER][NEUTRAL] What, what did she give me? That's what I asked her, but.
[AGENT][NEUTRAL] 52.
[CUSTOMER][NEUTRAL] That's not the CPT code.
[AGENT][NEUTRAL] No, the CPT code is, um, usually the CPT codes are already in the system on the documents. Uh, CPT codes let us know what they did. So the, you know, the laboratory, um, pathology general, we know that, we know that code because we know thePT codes. Now, the diagnosis code is the reason why they have to have all these procedures done and that is what we're missing, the diagnosis code.
[CUSTOMER][NEUTRAL] So, the diagnosis code, OK, so for all those, which I thought.
[CUSTOMER][NEUTRAL] That was on there that he had um
[CUSTOMER][NEUTRAL] He does.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Which is why they did all this. Where's C. diff.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Drugs.
[CUSTOMER][NEUTRAL] So then you just need the 11 code?
[AGENT][NEUTRAL] Yeah, it's one code. Sometimes it's 1, sometimes it's 2, but it's no more than 2. And it's just indicating uh the reason why you went to that um to the emergency visit was it um back pain? Was it an accident? Was it, um, stomach pain, um, why, why cause this to take place?
[CUSTOMER][NEUTRAL] Oh, OK, so it was just.
[CUSTOMER][NEGATIVE] What, what caused the, the C. diff? I don't know what caused it, um, but he had horrible cramping, so.
[AGENT][NEUTRAL] No, no, no. What?
[AGENT][NEUTRAL] Cramping. So cramping will be the diagnosis code. Now, we need that uh in the bill. We need that information that is gonna be on the itemized bill.
[AGENT][NEUTRAL] Um, uh, if you have you call the, yeah, if you call Western Hospital and let them know that you're trying to submit your own claim, um, they should be able to send you a, um, UB form or a HIFA form with that information, and that's what we're gonna need. That will have all the information we need.
[CUSTOMER][NEUTRAL] That's weird that they.
[CUSTOMER][POSITIVE] I think they said right I think why I, I'm positive she said we can't give you that because we're not in network.
[CUSTOMER][NEUTRAL] Or we don't work with.
[CUSTOMER][NEUTRAL] PCH
[CUSTOMER][NEUTRAL] THCS.
[CUSTOMER][NEUTRAL] The company, I mean the insurance company apparently so.
[AGENT][NEUTRAL] PACS um.
[CUSTOMER][NEUTRAL] But does that make sense? I mean.
[AGENT][NEUTRAL] No, um,
[AGENT][NEUTRAL] No, uh, basically this is going to be through us, which is [PII], um.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] No, all you need to ask them is to send you a UBO4 form.
[AGENT][NEUTRAL] To send it directly to you.
[CUSTOMER][NEUTRAL] OK, and then I send that to them.
[AGENT][NEUTRAL] You can send, they will send it to you, you will send it to us because that's what we're waiting for.
[CUSTOMER][NEUTRAL] Oh, OK, what is the form? OK. For, what is it called again?
[AGENT][NEUTRAL] It's a you
[AGENT][NEUTRAL] UBO 44.
[CUSTOMER][NEUTRAL] U as in umbrella. B as in boy.
[AGENT][NEUTRAL] Yes, 04.
[AGENT][NEUTRAL] 04. Mhm.
[CUSTOMER][NEUTRAL] 04 OK OK 04.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And they should send it to me.
[AGENT][NEUTRAL] Yes, just let him know that you need a copy of that UBO4, yes.
[CUSTOMER][NEUTRAL] OK, try them again.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] KUBO4 form. OK.
[AGENT][NEUTRAL] And that's
[AGENT][NEUTRAL] Yes, and that's gonna have all your coding. Yeah, that's all you need in that form, you're gonna see all the CPT codes, the diagnosis code, the information of the provider, the information of the facility, the information of the patient, so everything is in there.
[CUSTOMER][NEUTRAL] And that's all I need.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Everything OK, all right, gosh, thank you so much. I'm learning.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][POSITIVE] All right, I'll call them right now. Thank you.
[AGENT][POSITIVE] You're welcome. Is there anything else I may help you with today?
[CUSTOMER][NEUTRAL] No thank you so much I appreciate trying to figure this out.
[AGENT][NEUTRAL] Yeah
[AGENT][POSITIVE] You're welcome and thank you for calling APL. You have a good afternoon.
[CUSTOMER][POSITIVE] You too. Thanks so much. Bye bye.
[AGENT][POSITIVE] You're welcome. Bye bye.