AccountId: 011433970860
ContactId: b35f3562-c235-450e-bc7f-0e027a15a8c3
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 638859 ms
Total Talk Time (AGENT): 235122 ms
Total Talk Time (CUSTOMER): 281911 ms
Interruptions: 3
Overall Sentiment: AGENT=0.4, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/14/b35f3562-c235-450e-bc7f-0e027a15a8c3_20250414T20:52_UTC.wav
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[CUSTOMER][NEUTRAL] He wasn't.
[AGENT][NEUTRAL] Thank you for calling ATL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Good afternoon, [PII]. My name is [PII]. Um, I have a policy with APL and I have a question about two claims. I wonder if you can help me, please.
[AGENT][POSITIVE] Yeah, absolutely. Happy to check on claims for you. Do you have your policy number?
[CUSTOMER][NEGATIVE] Yeah, um, I think they changed, but the one for [PII], um, the outpatient is 021874, 0 gosh, sorry, 7247. I've messed you up now, haven't I? ML 8.
[AGENT][POSITIVE] Oh, you're OK. Thank you so much. It's all right, [PII]. I hear you.
[CUSTOMER][NEUTRAL] Sorry, it's the end of the day.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] All right
[AGENT][NEUTRAL] Maybe I did miss a number, [PII], I'm sorry. I got 0.
[CUSTOMER][NEUTRAL] Yeah, I said no, that was my mistake. Go on, you do it. 021877-247 ML 8.
[AGENT][NEUTRAL] I got, yeah.
[AGENT][NEUTRAL] Just missed that 7 at the end, sorry.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] All right. And then if I could just get your uh date of birth and address, please.
[CUSTOMER][NEUTRAL] My date of birth is [PII], and my address is [PII].
[AGENT][NEUTRAL] All right, perfect, thank you. And then do we have a claim number that we want to reference that we're checking? OK.
[CUSTOMER][NEUTRAL] We do.
[CUSTOMER][NEUTRAL] Yeah, I printed it off, I printed it off for the weekend. 342-693-0.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so that claim shows a denial stating um policy provides no benefits for treatment of conditions other than sickness or injury as defined by the policy.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Yeah. Years ago I had breast cancer and
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Then we keep finding something suspicious. So I don't know if this is to do with the diagnosis here, because I know I've had MRIs before and CAT scans, um, maybe not CAT scans, MRIs of the breast, which have been, that have gone through APL um because there was a, I actually had a ruptured implant, and, but they didn't know if it was cancer that's come back. So, you know, they couldn't decide, they, so they kept sending me for all these tests. So.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I, I was just concerned, you know, is it, is it the way that they, because my primary has put that um under my deductible, 66503 went towards my deductible. And I know AP will pick up under, up to $500 a day for the deductible part.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] So I was confused if, if the primary already processed it OK, because you know you have to have so many authorizations before you go through these things. I mean, they don't do these very, they don't do them lightly, which is, which is good news. Um, so I was, I don't know if maybe the way that the, the diagnosis codes were different, that maybe they put on here that, because it's, no, it wasn't an injury.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right, right.
[CUSTOMER][NEUTRAL] Um, sickness, it was, they thought it was to do with maybe cancer. So, you know, it was to rule out like a, a preventative, like I know that we do colonoscopies, they go through as preventative.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Um, yeah, cause
[CUSTOMER][NEUTRAL] So is it a diag you know, do I need to go back to the doctor and change the diagnosis?
[AGENT][NEUTRAL] Yeah, the, the code that they used was the one for an MRI it looks like um.
[AGENT][NEUTRAL] I wonder if I can think.
[AGENT][NEUTRAL] I was trying to see if I could find another one over here that was maybe paid out.
[AGENT][NEUTRAL] Under your other claims here let's.
[CUSTOMER][NEUTRAL] Yeah, I've been having
[CUSTOMER][NEGATIVE] I was not prepared for that question. I should have grabbed some of the other MRI's I've had.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I had one at, I didn't I have one at the end of the year last of like [PII]?
[CUSTOMER][NEUTRAL] Had a lot done
[CUSTOMER][NEUTRAL] I'm over it.
[AGENT][NEUTRAL] I hear yeah let me let me see.
[CUSTOMER][NEGATIVE] I'm over this
[AGENT][NEUTRAL] Let me see if I can search my code and see if I see anything else.
[CUSTOMER][NEGATIVE] What was the diagnosis code? Did they? I know you said they used an MRI code, but what was the actual sickness or the what um was it a preventative? I don't even know why I went. I mean, all I, I mean, you just don't go for no reason.
[AGENT][NEUTRAL] The code used, I mean, I, so I'm not a medical examiner. So, you know, I just kind of, um, the code used was one for MRI procedure of the breast. It includes both contrast and non-contrast.
[CUSTOMER][NEUTRAL] But what about the diagnosis? I mean, that's not a diagnosis, that's what I'm trying to figure out. I mean, you need a diagnosis in order to do the MRI.
[AGENT][NEUTRAL] Mm mm mm.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I do medical billing. I don't mean to be.
[AGENT][NEUTRAL] No, that's OK that's totally fine. Like I don't process claims or anything like that so all I can tell you is that that was what they I see on it, but let me pull the actual claim.
[CUSTOMER][NEUTRAL] It's flipping, um.
[AGENT][NEUTRAL] See what they sent with it.
[CUSTOMER][NEUTRAL] Yeah, cause on the, I'm looking at United Healthcare EOB.
[CUSTOMER][NEUTRAL] And they don't put diagnosis. I guess I could have to call [PII].
[CUSTOMER][NEGATIVE] Who were a nightmare to see if they could give me a diagnosis.
[CUSTOMER][NEUTRAL] Kite.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Yeah, that may just be all that they need on here.
[CUSTOMER][NEUTRAL] 7704 0 yeah, 77049, that's what they used. But that's the CPT code. I want the ICD 10 code 77049 is, yeah, that would be.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Breast MRI OK. So that's the CPT code, but I was, you know, wondering about the diagnosis.
[AGENT][NEUTRAL] Yeah, it doesn't look like they, I don't, I don't see any, honestly, all they said was
[CUSTOMER][NEUTRAL] Which does not show up on here.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Yeah, just that. I don't.
[CUSTOMER][NEUTRAL] Let me see if I can log into.
[CUSTOMER][NEUTRAL] United Healthcare cause I think I had another one at the end of the year last year before I had surgery.
[CUSTOMER][NEUTRAL] Uh, I think it's called My United Health.
[CUSTOMER][NEUTRAL] QHC.
[CUSTOMER][NEUTRAL] UHC.
[CUSTOMER][NEGATIVE] Yeah it is. No, no.
[CUSTOMER][NEUTRAL] www.
[AGENT][NEUTRAL] So, yeah, they may just need diagnosis on that, but if you want, [PII], I'm happy to get somebody over in claims that processes these if you wanna speak to them too, um, just to make sure, yeah, that you get all the right information as far as what you need. So let me give them the claim number and everything. Do you mind if I put you on a hold for a moment?
[CUSTOMER][POSITIVE] Yeah, that'd be great.
[CUSTOMER][NEUTRAL] Not at all, no, and I'm actually seeing if I can log into United Healthcare cause I know I had another.
[CUSTOMER][NEUTRAL] I think it was an MRI image at the end of last year, and to see if that one went through.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] You as well to see how that 10 yeah, I'll, I'll be right here. Thank you.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK, no problem. One second.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] It's part of this.
[CUSTOMER][NEUTRAL] s f er ring
[AGENT][NEUTRAL] Mhm
[CUSTOMER][POSITIVE] Good afternoon. Thanks for calling APO. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hey [PII], this is [PII] over in customer care. How are you?
[CUSTOMER][POSITIVE] Oh, I'm good how are you?
[AGENT][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's just like medical billing and I'm just not.
[AGENT][NEUTRAL] I don't know all this stuff, so can you maybe help?
[CUSTOMER][NEUTRAL] OK, what's the policy number?
[AGENT][NEUTRAL] It's 021-87247.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK, and what's the claim number she's calling on?
[AGENT][NEUTRAL] And then her
[AGENT][NEUTRAL] It was 342-693-0.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, so she explained to me that she's had some other MRI's 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.
[AGENT][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.
[CUSTOMER][NEUTRAL] OK, you can send her on over.
[AGENT][POSITIVE] Thank you, appreciate you. Here she comes.
[CUSTOMER][POSITIVE] Alright, no problem.
[CUSTOMER][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.