AccountId: 011433970860
ContactId: ab90c48c-f853-4044-a707-3f59ef70d609
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 611349 ms
Total Talk Time (AGENT): 192459 ms
Total Talk Time (CUSTOMER): 347575 ms
Interruptions: 2
Overall Sentiment: AGENT=0.8, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/14/ab90c48c-f853-4044-a707-3f59ef70d609_20250414T21:01_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thanks for calling APO. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey [PII], this is [PII] over in customer care. How are you?
[AGENT][POSITIVE] Oh, I'm good how are you?
[CUSTOMER][NEUTRAL] I'm good thanks for asking um I have an insured on the line with a denied claim that she has some questions on, and I was giving her the denial, um, but she wants more information she does like medical billing and I'm just not.
[CUSTOMER][NEUTRAL] I don't know all this stuff, so can you maybe help?
[AGENT][NEUTRAL] OK, what's the policy number?
[CUSTOMER][NEUTRAL] It's 02187247.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, and what's the claim number she's calling on?
[CUSTOMER][NEUTRAL] And then her
[CUSTOMER][NEUTRAL] It was 342-693-0.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, so she explained to me that she's had some other MRIs that she's had done, uh, before that have been paid, and so I, you know, I advised her that, you know, it was saying that it wasn't payable because of sickness, whatever, and she said, well, did you get the diagnosis code? And I did look at the claim information. I did advise her.
[CUSTOMER][NEUTRAL] I did not see any diagnosis code. I'm not sure if that's what they're needing and I didn't wanna tell her one way or the other, so I figured maybe you would be better equipped to advise on what's needed.
[AGENT][NEUTRAL] OK, you can send her on over.
[CUSTOMER][POSITIVE] Thank you, appreciate you, here she comes.
[AGENT][POSITIVE] Alright, no problem.
[AGENT][POSITIVE] Good afternoon. Thanks for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Good afternoon, [PII]. My name is [PII], and I had a question about um a denied uh claim, please.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And she gave me the um data service [PII].
[AGENT][NEUTRAL] Uh, claim number 3,426,930, is that correct?
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Yeah. That's right. Yeah. 342-6930. Yes, cause it said the policy provides no benefits for the treatment of conditions of other sickness and injuries as defined on the policy. Um, I was just inquiring what diagnosis codes that they use, because I know I've had MRIs before and they have gone through APL um as, as you know, you can't just have an an MRI. Um, I've had breast cancer before and we had a suspicion about
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, a lump that they couldn't tell what it was with, you know, with regular research.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] So, um, but we couldn't find the diagnosis. We found the CPT code, but not the um ICP 10 code for it. And I'm just looking through my calendar cause I'm
[AGENT][NEUTRAL] Yeah, they, they submitted it.
[AGENT][NEUTRAL] We do have it.
[CUSTOMER][NEUTRAL] Oh, sorry. Yeah.
[AGENT][NEUTRAL] Yes, give me one second, yeah, let me give me 1 2nd to look at that claim.
[CUSTOMER][NEUTRAL] Oh, you have it, OK.
[AGENT][NEUTRAL] Yeah I
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] See what we got going on here.
[CUSTOMER][NEUTRAL] Yeah, and I had another one in [PII], so we can compare.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Compare.
[CUSTOMER][NEUTRAL] Which I didn't look up, um.
[AGENT][NEUTRAL] So you had one in [PII]?
[CUSTOMER][NEUTRAL] 24.
[AGENT][NEUTRAL] 0 2024, OK.
[CUSTOMER][NEUTRAL] I've had a lot going on with the boobs lately. Yeah, I had, yeah, you don't need to know my story.
[AGENT][NEUTRAL] OK, I'm sorry, OK, because I just didn't see that one in history, so that's why I was asking, but that's fine.
[CUSTOMER][NEUTRAL] That's OK.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I'm gonna see if I can log into your website while I'm
[CUSTOMER][NEUTRAL] Chit chat because I didn't look that one up while I was. I have some old people who send me old claims, you know, statements now. They're obviously getting up to date with their billing and so I'd like to just double-check that everything's OK before I pay what I need to pay.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] OK, yeah, it looks like we should have allowed those benefits uh we can go back and.
[AGENT][NEUTRAL] Have those claims reviewed again for payment.
[CUSTOMER][POSITIVE] I do appreciate that because that's a lot of money for me. Yeah, I was a little confused. I'm like, OK, what, what, what, why is it so different to all the others that I've had through, through the years? OK, that's, that's great if you could send that one back, that would be greatly appreciated.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Alrighty, and there was there anything else I can help you with on today?
[CUSTOMER][NEUTRAL] Yeah, I, there is actually a bit too picky. OK, so that one's going back, um, but I have another APL one here, um.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and I do have, I printed off your um EOBs at the weekend, so I was prepared. OK. And the EO your claim number for this is claim number 3557507.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] This was, I guess say the service on [PII]. Um, looking at the EOB from my primary, which is United Healthcare, the total amount went towards my deductible. It was $81.27 towards my deductible. The um the office code 99214 did not get paid because it's saying that you don't pay office codes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes ma'am.
[AGENT][POSITIVE] Mhm, that's correct.
[CUSTOMER][NEUTRAL] Oh, it didn't get covered, but I've had
[CUSTOMER][NEUTRAL] You know, everything that was under the deductible has been covered before for that calendar year. So I don't know why this one was picked out separately.
[AGENT][NEUTRAL] Now with the office visits, if you're uh because you have the cancer treatment writer.
[AGENT][NEUTRAL] And so being that uh.
[AGENT][NEUTRAL] But if you had claims that came in and they were diagnosed as they were for the treatment of cancer.
[AGENT][NEUTRAL] We will look at the diagnosis.
[AGENT][POSITIVE] And most of the time they, those office visits that were paid, those were for treatment of cancer and so we were able to allow those office visit benefits under the cancer outpatient treatment writer.
[CUSTOMER][NEUTRAL] Oh, so those are being paid. Yeah, this is what I get, yeah, this one, he's a, he's a heart specialist. Um, I have high cholesterol, so I go to see them all the time. Um.
[AGENT][NEUTRAL] So, on this one.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so you're saying if I go back and look at all of his visits, you haven't paid the office visit before? And I think you have. I think you have.
[AGENT][NEUTRAL] So the office visits that are just for just a regular sickness.
[AGENT][NEUTRAL] Uh, let's see
[AGENT][NEUTRAL] Let me look at the office business that we have paid to insure.
[CUSTOMER][NEUTRAL] Yeah, that's why I was getting a bit confused. Um, let me look for another um
[AGENT][NEUTRAL] Uh yeah.
[AGENT][NEUTRAL] Yeah. I don't, yeah, I only see one office visit that we had that was uh that had a diagnosis for the cancer.
[AGENT][NEUTRAL] And so those were considered under the cancer outpatient treatment writer and that one was back in [PII] but we, we haven't made a payment on it yet because we were needing the explanation of benefits from your primary insurance carrier so that we can see how much was applied to your deductible to make a payment on that claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Nobody's asked me about that. That's [PII]?
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] Um, who is that for? Doctor [PII], the cancer specialist?
[AGENT][POSITIVE] I can check for you.
[AGENT][NEUTRAL] Give me 1 2nd.
[CUSTOMER][NEGATIVE] Cause I
[AGENT][NEUTRAL] 6107.
[AGENT][NEUTRAL] Uh, yes, that's correct, [PII].
[CUSTOMER][NEUTRAL] [PII], yeah, she's my cancer specialist. OK. What date in [PII], is there something that I can send over to you? Or are you waiting for it from them?
[AGENT][NEUTRAL] Uh yes ma'am.
[AGENT][NEGATIVE] We're waiting for it from them but as of today we have not received it.
[CUSTOMER][NEUTRAL] OK, because
[AGENT][NEUTRAL] Uh, so if you, yeah.
[CUSTOMER][NEUTRAL] Wow, OK. What
[CUSTOMER][NEUTRAL] Yeah, what date in [PII] was that?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] That you love.
[CUSTOMER][NEUTRAL] [PII]. So you're looking for the, oh, I don't know if I had then.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Does it say who I had?
[AGENT][NEUTRAL] Uh, let me check to see if it's.
[CUSTOMER][NEUTRAL] Yeah, I probably had United Health, yeah, I probably did.
[AGENT][POSITIVE] Uh, it shows AMed.
[CUSTOMER][NEUTRAL] I think it was.
[CUSTOMER][NEGATIVE] Oh, [PII] gosh, no wonder. You're a nightmare.
[CUSTOMER][NEUTRAL] Oh, I might not be able to get that then.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I don't know if I'll be able to log in. If I can, um, I'll gladly, um, send it over to you. What
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, can I do, I don't have fax capability. I can mail it or I can email it.
[AGENT][NEUTRAL] Um,
[CUSTOMER][POSITIVE] Yeah, I don't know if I can do it, but I'll try for you.
[AGENT][NEUTRAL] Yeah, email is not a secure means of submitting the claim information so we can do mail.
[CUSTOMER][NEUTRAL] Doctor [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Do you have a web portal? Oh, now, OK.
[AGENT][NEUTRAL] Uh, yes, you can do it online service center and you can upload it there.
[CUSTOMER][NEUTRAL] Oh, OK. I can do that too, right. And if I do it by the mail, it's the number on the, the address on the back of your card, 2489, this is the [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Mhm, that's correct.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] OK. Oh well, I'll look out for that then. OK, well, if you could send that other one back, I'll contact that company because they're chasing me for that money, and I'll let them know that I hadn't forgotten about them, that you're gonna reprocess that for them.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, all right.
[CUSTOMER][POSITIVE] Perfect. Well, perfect. Do you give call reference numbers, [PII]?
[AGENT][NEUTRAL] We do not, you can use my name in today's date.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] In today's date. OK, [PII]. Perfect. Well, thank you very much and you have a nice rest of your week.
[AGENT][POSITIVE] You as well, Miss [PII]. If there's nothing else, you have a great rest of your weekend and a great day as well.
[CUSTOMER][POSITIVE] Thank you. Bye-bye. Thank you.
[AGENT][NEUTRAL] Bye bye.