AccountId: 011433970860
ContactId: b0013d35-2104-42c6-b173-f9aefbb59f93
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 466739 ms
Total Talk Time (AGENT): 185500 ms
Total Talk Time (CUSTOMER): 77376 ms
Interruptions: 0
Overall Sentiment: AGENT=0.5, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/04/b0013d35-2104-42c6-b173-f9aefbb59f93_20250404T20:11_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APR. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi. Um,
[CUSTOMER][NEUTRAL] Hello, can you hear me?
[AGENT][NEUTRAL] Yes, ma'am. I can hear you.
[AGENT][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] Yes, um, I have a claim that um.
[CUSTOMER][NEGATIVE] They, it was denied saying that my services are not uh included.
[CUSTOMER][NEUTRAL] And um I needed to speak to somebody regarding that.
[AGENT][POSITIVE] Yes ma'am, I can assist you with claim status. First, could I get your name and a good callback number?
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][NEUTRAL] Thank you, [PII]. Now I need your policy number, please.
[CUSTOMER][NEUTRAL] One second please
[AGENT][NEUTRAL] And if you don't have your policy number, I could pull up the claim by your social.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, yeah, I have this policy 018.
[CUSTOMER][NEUTRAL] 325
[CUSTOMER][NEUTRAL] 20 ML 8.
[AGENT][NEUTRAL] Thank you. Um, please verify your name again and your date of birth.
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][NEUTRAL] OK. Thank you, [PII]. Now, please verify your mailing address and your email address.
[CUSTOMER][NEUTRAL] [PII]. [PII].
[AGENT][NEUTRAL] OK, thank you. And the claim you're calling about, is it for you or one of your dependents?
[CUSTOMER][NEUTRAL] For me?
[AGENT][NEUTRAL] OK. And what's the date of service on the claim?
[CUSTOMER][NEUTRAL] Um, it was [PII].
[CUSTOMER][NEUTRAL] For an MRI?
[AGENT][NEUTRAL] OK. Yes, ma'am. I found the claim. One moment, please.
[AGENT][NEUTRAL] OK. Yes, ma'am. I'm showing that this claim denied because of the diagnosis um that the provider placed on the um on the claim. They're showing that the claim was not for an illness, that it was um just for a screening. And under this policy, screenings are not covered. Um, if the diagnosis has to be related to an illness or an injury.
[CUSTOMER][NEUTRAL] OK, but it's been covered in the past. It's the same.
[CUSTOMER][NEUTRAL] It's the same type of MRI that I've had before, based on the same.
[CUSTOMER][NEUTRAL] Same diagnosis, so.
[CUSTOMER][NEUTRAL] Other ones have been covered.
[AGENT][NEUTRAL] OK. Um, do you have a, let's see, do you have a date of service for the claim that was covered in the past and I could verify if the diagnosis code is the same?
[AGENT][NEUTRAL] Because we can only go by the, yeah, we can only go by what the provider sends us. Now, if the provider resubmits the claim with the updated diagnosis, um, the claim can be reprocessed. But according to the documentation that they sent us, they're showing that this was just for screening and like I said, screenings are not covered.
[CUSTOMER][NEUTRAL] I, no, I don't have any.
[AGENT][NEUTRAL] But it can be resubmitted if um if it is in fact related to an illness.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK, and you can see the one that was done in [PII]?
[CUSTOMER][NEUTRAL] It was, um, probably [PII].
[AGENT][NEUTRAL] OK. I'll try to see if I can find that 11 moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. I've searched through [PII] and [PII] and I'm not showing any other claims on file with that same procedure code.
[CUSTOMER][NEUTRAL] OK. What are you showing other MRIs?
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] I am showing other MRI's but these are all related to an illness and they were paid.
[AGENT][NEUTRAL] The diagnosis code listed.
[CUSTOMER][NEUTRAL] OK, um, can you tell me what the code is that they use then?
[AGENT][NEUTRAL] Um, not unless you give me a date of service and the bill charges. I wouldn't be able to just give that information out over the phone because of HIPAA.
[AGENT][NEUTRAL] Um, have you set your policy up online where you'll have access to all of your claims, um, history?
[AGENT][NEUTRAL] Because you do have access to all of this information.
[CUSTOMER][NEUTRAL] OK, um, what's the website?
[AGENT][NEUTRAL] OK, let me know when you're ready, um, if you'd like to write it down.
[CUSTOMER][NEUTRAL] Yeah, one second.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, go ahead.
[AGENT][POSITIVE] It is secured, that's [PII]
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So [PII]. When you go there, you'll see a blue button and it will say new user.
[AGENT][NEUTRAL] You'll click on the button, letting the system know that you're a new user and then you'll choose the selection that you're an individual, and from there you'll answer the questions to set your policy um up online and from there um you'll be able to log in and you'll have access to all of your policy and previous claim information.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK. Is there anything else that I can assist you with?
[CUSTOMER][NEUTRAL] No, that's it.
[AGENT][POSITIVE] OK. Well, I thank you again, [PII], for calling APL. You have a great weekend. Bye.
[CUSTOMER][POSITIVE] Thank you bye bye.
[AGENT][NEUTRAL] You